Ridryder 911

I do understand the dangers of especially Dilantin tox. etc... the protocols were specific on history of ..."Hx. off non-compliant to Dilantin".. draw and obtain Dilantin level, then start on loading dose... of course monitor, etc.. My medial director was very visionary, since this was over 18 years ago..we performed it quite often, since the number one cause of seizures with hx. of such is non-compliant to med.'s... Yes, it did reduce the seizures, and yes we were allowed to administer muscle relaxants, (Valium, etc..) as well. Definitely, something that needs formal research, may be a bad idea, or good.. it worked at that system in a very rural, poor economic area.... R/r 911

Maybe, we should start considering true "seizure" med's. I worked at a service that we carried Dilantin and Cerebyx, if the patient was a known seizure patient, and had been on Dilantin, with a hx of < or absent Dilantin. Baseline levels were drawn prior to administration. Treating again the etiology, not just the symptoms. I agree, so many think because we have stopped the external symptoms the seizure has stopped... "a foolish thinking".. inside the brain maybe still seizing, it is we now just don't see the seizure. We need to explore and research more treatments for seizure patients and aggressive therapy. R/r 911

The Old Saying "..... You can't fix what you don't know is broken....." is so true. Yes, I agree basics should be taught; however it is not true that they are. Watch the examinations of basic exams, and NREMT exams, it is a joke! Yes, they go head to toe, checking PEARL, abdomen with the tips of the fingers and not aware that the lower quadrants really are below the belt line. Now, when you ask the basic EMT what does it mean when one does not have equal pupils, the answer will always be ...head injury..okay why ? 99.99% you will receive a blank stare. All levels of EMS students are not really taught detailed assessments. Although it is true most of the time our assessment have to be curtailed and narrowed and not practical in most cases, this should not remove us from having the general knowledge and capability of performing a thorough assessment. It is common comments among the health care professional that Paramedics have very poor assessment capabilities. Would it not be better to have the knowledge of how to perform focused assessments than the usual assessment techniques that is being taught now? How many Paramedics can actually perform a true neuro examination or be able to detect that S[sub:7aa06bb858]3[/sub:7aa06bb858] heart sound with hollow systolic murmur.. and why not? They are wearing that $200 stethoscope Most reasons students and even field personnel are lacking in assessment skills is because they never performed very many or watch and study assessment skills. Again, it goes back to those clinical activities while in school. Did you follow others and watch and ask to perform concurrently while assessment are being performed? Were you checked for accuracy of your assessment skills? ... The only way to know abnormal findings from normal is by doing and performing assessments, hundreds, thousands.. on each and every patient when applicable. The best time is on the non-emergency patients. Perform an assessment, listen to lung sounds, heart tones, check capillary refill time, skin turgor..... where do most patients with edema first have symptoms at?... hint it is not the ankles.... Yes, one has to master assessment skills not only didactically, but clinically as well.. this takes time and one has to keep performing and practicing to continuously be profound at it. Again, practice, practice, practice... watch others, ask questions afterwards, ask for others to watch you to gain insight on your techniques... There are many books I highly recommend : one of them is Bledsoe, Cherry Paramedic Patient Assessment (paperback pocket size ) $19-23.00 http://www.amazon.com/gp/product/013117833...2536043?ie=UTF8 and several others that go into great detail. 'Good luck, R/r 911

Well so far we have proven we have WAY too many.. eliminate the all between. Either you your First Responder, B0asic or Paramedic.. short and simple. Decrease all the expenditures and do it correctly.. You don't have time or money to expand your career... then don't. When you have achieved that level, then proceed to waddle through and pretend or be similar. Too many excuses allows to many variables. R/r 911

I agree, we do not know the extent of the crash, I too have seen some that was so severely mangled, that delayed extrication was required. Unfortunately, there are several other factors that paints a picture of gross negligence, and incompetence, not poor training or lack of. Let's simplify this by looking at the basic factors Duty to respond - Yes Damage/death occurred - Yes Such action caused death- Possible Is action in accordance of standards and other equally trained would perform - No hmmm Don't look to good for the home team... better get that check book out. Cancelling air lift on a severely critical patient, then transporting and the ambulance broke down then in a pick-up ? WTF ?.. Not having gas in a hydraulic tool?.. Not knowing how to properly extricate?.. The nail in the coffin is the excuse or even lack of one.. we do the best we could. Really? Well for that million dollars the town could had a real EMS and Fire.. sorry, the point is again not about the feelings of the volunteers.. it is about patient care. Paid or volunteer... Now the citizens of that small community will have to suffer, with increased taxes, probably dissolve of their EMS, etc... to pay off the suit. When all could had been resolved with responsible persons, maintenance, and proper education... Sorry, this tragic event occurred.. worst, this type of incidence occurs daily, we just don't hear about it. R/r 911

The old saying if you see V-fib in a ped's case, check your own pulse... Yeah, this is nothing new than what other previous studies have prevailed. That is why I am concerned that so many EMS and first responder units are so concerned about changing their AED's for pediatric.. <8 % V-fib witnessed = rarely to never in the field. It would be wise to spend your money on proper equipment such as Braslow tape & kits, proper BVM's oxygen supplies and suction catheters. R/r 911

Very awakening video Ays.. makes a good point, that all patients should be patted down and never ASSUME anything. One of the most dangerous situation I was placed in was from an 80 year old granny.. who wanted her purse to check to see if she had her medicare card. She did as well as a .38 caliber, in which she pointed at me .. and demanded we not take her to the nursing home.... we didn't. I never hand purse, medication bag(s), etc, without searching first, and I attempt to "patt" all patients down 1'st. I can't tell you how many patients arrive in ER "packing" ... Be safe, R/r 911

First Welcome to the City! Congratulation on your decision to follow your calling. I will not go into detail, but I know of many that too that had great intentions to enter the ministry (including myself) and after entering EMS or other health care never did. Of course, there are as many circumstances of why not, versus the number of the people. I have found man like in my personal history was very sheltered and was not exposed to the elements of human nature, the sociology and deversements of people and the "true world". This may not be your case, but I do believe one entering the ministry this definitely would be extremely helpful and shed light on human behavior. There are so many people that are so unaware of what the true world is like, and how people live their life. Now after saying this, I will forewarn you... many, become very jaded, and calloused. This sometimes can have a detrimental effect on some, and changes many outlook on some view of life and people in general. Just be aware of the side effects of health care... Thoughts and prayers on whatever the decison maybe, Good luck R/r 911

AK although it sounds like a good idea, unfortunately not all states allow photocopy, some will only get a print that says "Licensed".. or VOID nothing more. For some states it is illegal to even copy state medical license, some will not recognize a copy as the same as on the sate drivers license (OK does not). My suggestion is one needs to be very aware of local and state requirements. Some will require additional cert.'s & license, here we must also have an AHA- current CPR, and if a Paramedic an ACLS card as well. Our field investigators routinely will spot check you at local ER entries while getting your unit back into service. Trick of the trade, keep 4 manila envelope, every time you attend a conference, copies of any cards, cert.'s place a copy into each on of the envelope, one is for a copy for you, one for State, one for NREMT (if applicable), one for your local service. Then when it is time to re-cert it is easier to gather, and you already have a copy of everything. So many procrastinate, and become frantic... Here is a pet peeve of mine.... every time you need a strip of tape, you cannot get the end (especially with gloves on) fold one corner over and you have a start that is easy to get the tape off. Good topic AK.... R/r 911

You need to talk to the Human Resource Director, etc. Be sure to have each agreement in written form. There are some that will provide tuition reimbursement, if you sign a contract or some will re-pay you if you pass, etc.. again, many options & I am sure they have all the details. R/r 911

Don't F*ck up, one would not have to worry!.. Don't be an idiot and bring liquor to workplace. Short and simple, this should not be even a discussion. If they had brought a bottle of vodka or whiskey, or a bag of weed, no one would be complacent, beer is alcohol... no difference. R/r 911

First Welcome to the City......My feathers are not ruffled but disappointed. A Paramedic should also have basic knowledge of grammar, and English composition as well. As you described "jumping" levels, I too believe we have allowed too many to jump education levels. Let us require reading, writing, and basic mathematics before allowing entrance into a health care profession such as Paramedic. Obviously, too many have "jumped" that level as well. Yes, it is scary sometimes, I concur with that. But, because someone has experience does not always mean that it is good experience. One can be an idiot for several years, and not know it. Get the required education and experience, you can always obtain the experience level with time. Logistically, and very unrealistically to expect EMS students to have experience. The job market is not that favorable. In my state alone, (which is considered rural) there are over 5000 basic EMT's... now when comparing that there is only 198 EMS services and almost a 1/4 of those are filled with advanced to Paramedic, how many positions would be available for the basic?.... neal to none?.. Now, compare this on a Nationwide Scale.. again, basic mathematics will tell you the answer. Again, wlecome to the city! R/r 911

For those that need visually to see what one looks like, here is what a La Forte Fxr. is .....

Your right, as well a common symptom is the "slapped face" appearance of the rash on the cheek, sometimes also the "butterfly" rash that spreads around eyes and down nose... The Fifth Disease was not named after a Dr. named Fifth etc... " but rather to the fifth of six classic exanthems, or rash-associated diseases, of childhood. The numbering was of medical historic interest only: the other rashes, in order are first: measles; second: scarlet fever; third: rubella; fourth: "Dukes' disease", which was never clearly understood or able to distinguish from other rashes. Which is now thought to have been either the measles, rubella, scarlet fever, a Staphylococcal infection, or one of several enteroviral infections; and sixth: was Rosella. ... Now don't we feel smarter! Now someone can discuss cor pulmonale.... R/r 911

Here's a suggestion, go to your local community college that teaches EMT-Paramedic. Talk to the financial counselor & apply for scholarship and potential Pella grants etc... take some additional classes like anatomy, physiology, English, etc..You can get that grant/loan, you can actually use any of those classes for later studies, what ever your decision might be. Don't fret over Basic EMT, it is not that difficult of a class if one studies and applies themselves !... Good luck, R/r 911

You know it is a shame this thread is not lighting fires... if it was a discussion of red lights, or how many star of life's it takes to cover your windshield, or maybe how many times can I fail the National Registry before I should call it quits..... we be hitting triple digits by now...but alas it is over something silly like medicine and medical care! Okay next Honk Case.. even the basics should have an understanding: Cor Pulmonale R/r 911

Got a camera phone... click it.. & call the City Manager/Mayor. This is not rocket science folks..it is an illegal substance at the work place, beer, Vodka, weapons, drugs it is all the same. If they gave me sh*t about it, I call the chief @ home, if need be. If need be they get in line for a pee test as well. He definitely does not want the press to get involved... you can kiss their careers good by for being stupid... in my opinion good riddance, we don't need any more idiot's .. and if your that stupid to bring alcohol to work place, then so be it.... then your obviously have no common sense to deal with someone life. R/r 911

You can only do so much... inform him of the risks, I would have him repeat the risks back to me and have the officer witness it. The dilemma of is he able to make a rationale decision is always a tricky question, as much is he is NOT able to make a informed decision or not as well? Yo cannot force anyone to go with you, I too would had left the patient in the competent hands of the LEO. See if they can get a friend to take him (doubtful) etc... For as the medical control, I would tell them: You come out and accompany him!.. You can't place a unit down hunting and acting like a babysitter! R/r 911

I agree talk to them allright;.. let them know that they were stupid enough to bring it into the station, their too stupid to be on the truck.... then I call the Chief and let them hash out the details... We have enough idiots as it is. R/r 911

Kawasaki Disease: No not associated with motorcycles :roll: One of the few disease they test on for RN boards. I am sure Dust has seen far more that I have. Primary childhood disease, unsure etiology. Primary seen in Asian decent however not always, can be ethnic group. Can lead to vasculature problems (valves, arrhythmia's) such as cardiac if not treated. Usually signs & symptoms are a fever that will not disappear (>5 days), blood shot eyes, rash predominately on hands, enlarged lymph nodes, and chapped lips etc.. Treatment is usually gamma globin .. I have seen 2 or 3 cases....very interesting presentations. Okay here is an interesting one, we see a lot in ER.. 5'th disease.. ? Oh by the way what were the other 4 previously? R/r 911

Real Call this a.m. :7-6-06 0024 Responded to a 56 y.o. white female, with history of fever. F.D. upon scene and stated " family says her sugar was high (300 mg/dl) we repeated it & at was 200 for us. Patient somewhat sitting in upright position, (leaning over) on bed. Room dissarayed. Presentation: 56 year old female grossly obese (>150 kg) very pale, extremely diaphoretic, distal extremities slightly dusky to taint cyanosis. Patient is awake however confused of surroundings, events. Incident History : sister of patient (who herself appears to be in grave health) described that patient acutely became worse, FSBS performed. Patient was recently discharge from hospital 2 days ago with pneumonia. History : Patient has outstanding history of COPD (asthma), CHF, Type II DM, HTN, etc... Meds: Numerous, brief scan noted , Z-pack, home nebulizer fual med's, HCTZ, Lasix, NTG, Pepcid, Glucophage,Prednisone, home C-pap machince, etc... Clinical findings: as noted intermittent <LOC, however responsive to stimulus and occasionally attempts to make jokes, skin cool, clammy. MMM pale, sticky, gummy. Pt. on 0[sub:f86d121fa8]2[/sub:f86d121fa8] @ 3 lpm N/C Head , PEARLA @ 2.5 mm each, when responsive, EOM's intact, facial symmetry, Chest: decreased t.v, hard to auscultate due to obesity and respiratory depth, however audible expiratory wheezes in upper lobes bi-lat., Hear tone rapid, clear with distinct S[sub:f86d121fa8]1[/sub:f86d121fa8] S[sub:f86d121fa8]2[/sub:f86d121fa8] without murmurs or clicks, APMI non-measurable at time. Abdomen: as noted extremely obese, soft, palpable .. does c/o slight grimace with palpation of mid lower right hypochondriac region. Extr.: anasarca, +3-4 edema , grade +1 pulses, clubbing noted @ 20 degrees EKG: S.R. no noted ectopi, or ST elevations or axis deviation noted from XII lead. S[sub:f86d121fa8]p[/sub:f86d121fa8])[sub:f86d121fa8]2[/sub:f86d121fa8]": initally 80% ETCo2: 35 mm/torr V.S. BP 90 palpation Pulse 106-110, R/R 18-24 TX: FSBS checked 220 mg/dl, Oxygen increased to 15 lpm per NRBM, with preparation of CPAP, and possible RSI. IV initiated with NSS bolus of 250 ml. Combi med's adm. per mask nebulizer, noted in creased tital volume as well as SpO2 incrasing to 94%, patient describing Sh.O.B decreasing. Ausculatation noted increased air movement with slight consolidation left lower lobe. Repeated question of GI.. patietn admits having dark tarry stools lately ... ? predniosne =G.I. bleed ? Advised ER of patient conditions of possible HHNC versus G/I bleed, COPD or all.. Outcome: patient was dx. with HHNC, placed on Insulin drip, after series of lab's, CT etc, small lower GI bleed detected as well as diffuse pulmonary infiltrates and tx with antibotics, RT tx'x, etc.... admitted to ICU with potential good prognosis Hyperosmolar Hyperglycemic Nonketotic Coma WOW ! or more commonly known as : :shock: HHNC, hyperosmolar coma, diabetic nonketotic coma, hyperosmolar nonketotic state, diabetic hyperosmolarity, diabetes, hyperglycemia, diabetic ketoacidosis, DKA, adult-onset diabetes, dehydration, sepsis, pneumonia, urinary tract infection, UTI, diuretics, beta-blockers, histamine 2 blockers, H2 blockers, stroke, intracranial hemorrhage, acute myocardial infarction, acute MI, acute heart attack, dialysis, gastrointestinal hemorrhage, hyponatremia.... Hyperosmolar hyperglycemic nonketotic coma (HHNC) is generally a metabolic derangement that occurs with patients with adult-onset diabetes (Type II non-Insulin dependent). The condition is characterized by hyperglycemia (usully > 200mg/dl although may not extrememly high), hyperosmolarity, and an absence of significant ketosis (such as ketones on breath/ Kussmaul's respirations). According to e-med despite the name : ...."Coma is present in fewer than 10% of cases. Most patients present with severe dehydration and focal or global neurologic deficits. In many cases, the clinical features of HHNC and diabetic ketoacidosis (DKA) overlap and are observed simultaneously.....". What happens pathophysio:: HHNC is most comon to develop in diabetic patients who have other illness that leads to a reduced fluid intake. Infection is the most common cause, but many other conditions can cause altered mentation and/or dehydration. Frequently, this other illness is not easily identifiable. The hyperglycemia and hyperosmolarity lead to osmotic diuresis thus causing a big time osmotic shift of fluid to the intravascular space, resulting in further intracellular dehydration ( can you see the shock appearance?). Patients with DKA, is not like patients with HHNC they do not develop ketoacidosis, but the reason for this is still not clear. How often does this happen (frequency) In the US: The incidence is 17.5 cases per 100,000 people. This incidence is slightly higher than the incidence of DKA Although I believe it to be higher and often misdiagnosed. Death Rate : The mortality rate is high (10-20%). Sex: The prevalence is slightly higher in females than in males. Age: High in the 70's but as earl y as children Residents of nursing homes are at the highest risk, but the syndrome has been reported in patients as young as 18 months. Incident Preciding History: Most patients with HHNC have a known history of diabetes, which is usually Type II/ Non Insulin dependent Often, a preceding illness results in several days of increasing dehydration. Oral hydration usually is well because they ae unable to re-hydrate due to acute illness (eg, dementia, immobility, vomiting). A divers neurologic changes may be present, including the following: Decreased LOC such as drowsiness and lethargy Confusion Coma Focal or generalized seizures Visual changes or disturbances Hemiparesis Sensory deficits Physical: The general appearance and hygiene may provide clues to the state of hydration (ion other words stinky!), presence of chronic illness, and reduced LOC. Vital signs As is seen in other dehydaration fast pulse (tachycardia) is an early indicator of dehydration; hypotension is a later sign suggestive of major dehydration. Orthostatic vital signs (tilt test) are neither sensitive nor specific. Fast respiratory rate (tachypnea) may result from respiratory compensation for metabolic acidosis. High rectal temp: One should assess core temperature rectally. A high or low temperatures suggest sepsis. Hypoxia can be a problem affecting mentation. Administer oxygen if the patient has any degree of desaturation or low sats'. Perform a thorough assessment including skin examination searching for sources of infection, such as cellulitis or abscess. Skin turgor is another clue to hydration status, with tenting (pulling of skin upright and staying there, good recoild is good turgor <3 seconds). Warm, moist skin suggests early sepsis where as cool, dry skin suggests late sepsis. Exam of the head, eyes, ears, nose, and throat (HEENT) may reveal altered hydration status (eg, sunken eyes, dry mouth) mucus membranes sticky, gummy.. Cranial neuropathies should be evaluated in detail by the Paramedic such as : . Visual field losses and nystagmus sometimes are observed in HHNC. The neck exam may reveal enlarged lymph nodes or meningismus. Palpation of the thyroid gland may reveal enlargement such as in thyrotoxicosis as a cause for tachycardia, fever, and dehydration. The lung sounds or pulmonary and cardiac examinations may reveal signs of pneumonia or of cardiac diseases such as Congestive heart failure (CHF), acute respiratory distress syndrome (ARDS), or atypical pneumonia which can trigger HHNC. Check for costovertebral angle (flank) tenderness as a sign of pyelonephritis (kidney area). Look for Kernig and Brudzinski signs (nuchal rigidity), which may suggest meningitis. A careful abdominal examination can help to rule out an intraperitoneal infection. A later rectal examination can screen for prostatitis, perirectal abscess, and GI hemorrhage. A later Pelvic examination is indicated in women with lower abdominal pain or purulent discharge. Causes: A current illness is common, but the underlying cause may be difficult to find. Pneumonia and urinary tract infections (UTIs) are the most common underlying causes of HHNC. A wide variety of other major illnesses can cause HHNC causing no patient mobility and decrease water to drink SUch as . Stroke, Acute myocardial infarction (MI), Gastrointestinal hemorrhage. Stress response to any acute illness tends to increase the hormones that elevate glucose levels. Cortisol, catecholamines, glucagon, and many other hormones have effects that tend to counter those of insulin. Drugs that raise serum glucose, inhibit insulin, or cause dehydration may cause HHNC. Such as Diuretics (Lasix, Demadex, some bood pressure medications) Beta-blockers Histamine 2 (H2) blockers (sinus medications, antacids) Patient being on dialysis, or having total parenteral nutrition (TPN) Not compliant with oral hypoglycemics or insulin therapy. Other Problems that need to considered or might mimick: Delirium Dementia Overdose Most of the time diagosis is usally based upon lab studies: such as : Serum electrolytes (sodium, potassium, chloride, bicarbonate) and calcium, magnesium, and phosphate Hyponatremia or hypernatremia may be present. In the setting of hyperglycemia, hyponatremia (low sodium) is more common due to the osmotic effect of glucose pulling water into the vascular spaces. The body potassium is likely low regardless of its serum value.An anion gap metabolic acidosis may be present because of dehydration (lactic acidosis) but usually is less profound than that observed in DKA. Most patients who have hyperosmolar, hyperglycemic nonketotic have a component of DKA; therefore, ketoacidosis therefore you will have a anion gap acidosis. Renal function (BUN (Blood Urea Nitrogen) basically waster prducts in the blood & creatinine levels) BUN and creatinine levels are likely to be elevated initially due to dehydration. Creatine phosphokinase (CPK) with isoenzymes should be measured routinely because an AMI and rhabdomyolysis can trigger HHNC, and both can occur from the complications of HHNC. Acute MI frequently is associated with HHNC. Coagulation studies (Blood clotting) prothrombin time [PT] and activated partial thromboplastin time [aPTT]) are useful as part of a screen for disseminated intravascular coagulation (DIC). Blood cultures should be obtained to search for bacteremia (bacteria) . Arterial blood gases ABG is the most accurate indicator of serum pH. A Urinalysis reveals elevated specific gravity (evidence of dehydration), glucosuria, ketonuria, and evidence of UTI. Urine cultures are usedl because UTIs may be not seen by urinalysis alone, particularly in patients with diabetes. Cerebrospinal fluid (CSF) fropm a lumbar spinal tap to check cell count, glucose, protein, and cultures. Prehospital Care: Standard care for dehydration and decrease LOC. Airway management, IV access, Isotonic saline etc... Comatose patients of course needs airway protection. Endotracheal intubation may be indicated. Measurement of ETCo2 may be an indicator of DKA versus Non-DKA. Bolus of 500 mL of saline is appropriate for nearly all adult patients with dehydration. A 250 mL bolus may be more appropriate in patients with a history of CHF and/or renal insufficiency. Basic medications given to most coma patients in the field may be thiamine 100 mg IV, dextrose (50 mL of D50), and naloxone (0.4-2 mg IV). This combination is of benefit to many comatose patients with few adverse effects. Of course a fingerstick glucose measurement is obtained prior to dextrose administration. Emergency Department Care: as per e-med. Manage airway as needed, establish IV access, initiate vigorous fluid resuscitation, and obtain appropriate laboratory and radiographic studies. Fluid deficits in HHNC are large; the fluid deficit of an adult may be 10 L or more. Administer 1-2 L of isotonic saline in the first 2 hours. A higher initial volume may be necessary in patients with severe volume depletion. Slower initial rates may be appropriate in patients with significant cardiac or renal disease or in those who are not urinating. After the initial bolus, some clinicians recommend changing to half-normal saline, while others continue with isotonic saline. Either fluid likely will replenish intravascular volume and correct hyperosmolarity; a good standard is to switch to half-normal saline once blood pressure and urine output are adequate. Once serum glucose drops to 250 mg/dL, the patient must receive dextrose in the IV fluid. Initiate insulin therapy in the ED. Although many patients with HHNC respond to fluids alone, IV insulin in dosages similar to those used in DKA can facilitate correction of hyperglycemia. Insulin utilized without concomitant vigorous fluid replacement increases risk of shock. Frequent reevaluation of clinical and laboratory parameters is necessary During neurologic examination, evaluate overall mental status, cranial nerves, strength, sensation, reflexes, cerebellar function, stance, and gait. Focal findings may prompt further studies such as CT scan and/or lumbar puncture (LP). Causes: A preceding or intercurrent illness is common, but the underlying cause may be difficult to ascertain. Pneumonia and urinary tract infections (UTIs) are the most common underlying causes of HHNC. A wide variety of other major illnesses may trigger HHNC by limiting patient mobility and free access to water. Stroke Intracranial hemorrhage Acute myocardial infarction (MI) Gastrointestinal hemorrhage Stress response to any acute illness tends to increase hormones that favor elevated glucose levels. Cortisol, catecholamines, glucagon, and many other hormones have effects that tend to counter those of insulin. Drugs that raise serum glucose, inhibit insulin, or cause dehydration may cause HHNC. Diuretics Beta-blockers Histamine 2 (H2) blockers Dialysis, total parenteral nutrition, and fluids that contain dextrose Elder abuse and neglect also may contribute to underhydration. Noncompliance with oral hypoglycemics or insulin therapy can result in HHNC.

It is based upon what is described as "impaled" and being stuck into the skin. I was in an instructors class when they were discussing, "one should never remove the stinger of a bee", since it is an impaled object... do what ? First, I would not consider this an impaled object, second we are going to allow secretion to continue from the stinger as well how is one going to "immobilize the object ?". I had a scenario on one of my trauma assessment stations of a mannequin that was stabbed in the neck with a syringe/needle. After making fumbling attempts to secure, (which incidentally caused the needle to move around) my instructor asked me if I ever seen ABG's, or biopsies performed? I answered yes, then he proceeded act like he talked to medical control then went to the mannequin and removed it with direct pressure. As he directed "just like any other needle stick" and applied direct pressure. Teaching common sense and looking at the "whole picture". Yes, immobilization of an object that can produce trauma to underlying tissue, nerve, blood vessels, etc.. but use common sense as well. As far as impending the airway, yes one can remove it, and from the cheek as well since both sides can be observed. R/r 911

Contact the chief, and tell them there is a 6 pack. I know that in this same state most cities have a local ordinance and policy of no alcohol on city property and definitely not at the work place...non excusable. In fact that is just pure boisturous that they want to get fired... and I would help them out. This is not a teenage camp... if they can't be more mature than that. R/r 911

Hypothetical question... You come across a lamp on the beach, and of course the EMS Genie appears and grants you 3 wishes for the EMS profession, what would they be...? (Sorry Dust, buxom blond, brunettes, red heads are not part of the deal) What would you wish for? Now another little twist... It has to be EMS profession related, it cannot be from a previous post (so be sure to read all the previous post) and there only can be 3! Let the fun begin... . R/r 911

It's hard being a medic and probably twice as hard being the spouse of a medic.. I have been both. Sorry, if I offended you that was never my intent. You need to learn part of this business is similar to military spouses and they have to be a special breed. It is not easy... no one ever claimed it, like others discussed try to meet with other spouses. You need to give him and especially you a chance... after you have been in this a while you will really see that it is a close knit family and we take care of each other as well as families of others as well. Things will get better.. I know it may not seem that way at first.. all of us remember the first holidays... it's hard. I realize it is hard being on both sides of the fence, remember we do care here and hopefully this holiday will be an exciting and better than you think... good luck, R/r 911