chbare

Initial BGL was 525, the current BGL is 370. This gives us a delta of 155 in 15 minutes. We typically do not want to drop BGL's by more than 100mg/dl/hour. I suspect cerebral edema. We have aggressively changed the osmolarity of the intravascular space with an isotonic solution as evidenced by the rapid drop in sugar. However, the intracellular space is still hyperosmolar compared to the intravascular space and water will move with the gradient. I have never seen this occur with a change in 155mg/dl; however, such a sudden change in this particular patient may be enough. We may need to bring her sugar up a bit. I would try to stay away from intubating a DKA patient if possible. We can really screw acid base/electrolyte balance up when we intubate a DKA patient and her vent settings will need close monitoring. Did my partner give any medications? Take care, chbare.

With the information I currently have, I would have to go with DKA. Take care, chbare.

The BGL is quite elevated, the most obvious problem to consider would be DKA. She will need worked up in any event. Can we obtain a 12 lead and initiate IV access? No history of any cardiac problems and her lungs are clear? If this is the case, we could administer some fluids. We should still consider GI pathology, infection, and toxins. Has she ingested any "exotic" substances? Take care, chbare.

"Once a woman's water breaks you want to minimize the number of times you insert something into the vagina as you increase the risk of infection." The importance of this statement cannot be over-emphasized. The information you gain can be quite subjective as somebody stated in a prior post. In addition, somebody who is 90% effaced and 9cm dilated can labor for minutes to hours. You can gain a great amount of information with a non invasive patient assessment. I will let the OB docs do the secret handshake. Take care, chbare.

As I understand the IV form is not available in the USA. The oral form is known as Dramimine an OTC medication used for motion sickness. In my experiences, it works well. Sedation is a common side effect with this medication. I understand the IV form is quite popular in Canada. Take care, chbare.

In addition, EPS are possible with Reglan administration. I have also used Reglan with good results for migraine hadaches. Take care, chbare.

You take a written exam and may do a group type megacode station. Remedial training followed by retesting is allowed, so people actually "failing" the course is quite rare. The individual ACLS course effectiveness will vary and greatly depends on the instructors. I remember assisting with a military course. We customized it for the medics. The course was a week long and contained a substantial amount of pharmacology, airway, physiology, and ECG related material. We actually set up aid bags and full megacode dummies in areas of the armory, had the medics leave the area, then called them for an emergency. The scenarios were based on emergencies that may occur while on a FTX or field training problem. The medics were in small groups and had to do the code from scratch. Scene, assessment, IV start, rhythms, etc. We had actual vials and tubex syringes of meds full of saline and IV's that went to 1 liter bottles. They had to calculate med doses and actually administer the proper dose of med. A good example of how an instructor could customize a course based on a specific level or type of provider. Take care, chbare.

The card is not even recognized by the AHA as a certification. ACLS is simply a course that reviews current AHA recommendations based on their interpretation of the current literature and data. Take care, chbare.

It is part of the human condition. Spend a little time working around Nurses, brutal. I experienced the same behavior bagging groceries in high school, in the military, as an EMT, as a CNA, as a LPN, in the ER as a RN, and in my current workplace. Take care, chbare.

Prior service 91B10 who ended up transitioning to 91W20. I met my ETS date about a year prior to the 68W transition. Take care, chbare.

Captianstandup, I would be careful about stating sweeping generalizations directed at an entire profession. EMS will never gain the respect it deserves until the individual providers put aside petty and selfish desires and concepts. EMS professionals must band together and demand sweeping changes in education levels, the work environment, and the legislation. This is how Nursing moved out of the dark ages. Unfortunately, how can we expect any changes when we have providers fighting over the color of the new first out bag or the size of patch to wear on their department jacket when they go out to eat? Please do not hate on other professions for the problems within the EMS community. We have only ourselves to blame for the sad shape of affairs in EMS. Take care, chbare.

Why take it out on the NREMT? They simply design an exam process based on the national standard curriculum. If the process is no longer prestigious, then you have bigger problems than the organization that provides the exam. Hence, the numerous discussions relating to EMS education and curriculum development. Take care, chbare.

I have to argee. The NREMT simply a test. Take care, chbare.

Nurses in a few specialty areas are allowed to perform invasive procedures. Flight Nursing would be an example. I am allowed to place chest tubes and place central lines. However, I think this does make an interesting point. A point that Dustdevil emphasized with his "9" year comment. I have had to spend several years obtaining education, experience, and credentials to have the ability to function with the autonomy of a medic and have the ability to provide similar interventions as a paramedic. The more I work in my current field, the more I wonder if my qualifications are actually adequate. Then, I look at my state. We have EMT's with less than 300 hours of training providing interventions and making autonomous decisions that are on par with what I do. How people advocate such an approach? If I understand the argument, it goes like this; This is the way my state does things and I cannot do anything to change that, so I just accept it? I also understand many people pull the "rural" card. People who live in rural communities should have access to high level EMS care as well as people in urban communities. Look at nursing, you go to a hospital and you expect a nurse to deliver your care. Even in tiny rural hospitals you have nurses. Yes, I know all about the push to replace nurses with providers with less education. The difference being, Nursing as a profession has chosen to aggressively fight this practice. Do we see this occur in EMS? I see only three types of people provide care as independently as some of these providers. Physicians, PA's, and Nurses with master's degrees. Food for thought? Take care, chbare.

Tracheal deviation is a late and often ominous sign that would be associated with a tension pneumothorax, if you are going that route. Take care, chbare.

Well, if it works for your service and you medical direction advocates this approach, I cannot say much. A few points to ponder: -A rescue device will establish an airway in a similar time frame without having to cut skin. -Even performed properly, a surgical airway is not without risk. -Having additional backups only provides you with additional tools and advantages. We utilize the 4 step approach to surgical airways at my service. I have yet to perform a cric in my year and some odd months of flying. I have assisted in performing 1 cric in the 5 years ER experience I had. However, I have seen rescue airways used with success several times. Take care, chbare.

Well, I guess you could go that route. However, if you had a highly effective rescue option that did not involve cutting, would you not consider utilizing that option? Take care, chbare.

Correct, the current AHA modalities only apply to the arrest situation. However, people seem to be pushing this into more aspects of airway management. I do not disagree that ETI will produce a more secure airway when properly performed; however, the trend appears to be moving away from ETI as a means of managing the airway in several areas. As more people utilize these "alternative airways" we will see more data on their use. I am curious to see how patient outcomes will change. I do not see people receiving proper airway education however. I see less OR time and less "real" intubations related to many anesthesia providers having concerns with liability and crowding of the OR's. (students) In addition, many cases are performed with the use of a supraglottic airway device. So, where does this put us as pre-hospital airway providers? I am curious to see where this will all end up. Take care, chbare.

I think we have gone a little off topic; however, I enjoy the discussion. With all of this arguing, I think we must accept a few facts: Many physicians and groups are advocating the use of "alternative airways" in place of traditional tracheal intubation. Even the AHA states in their published provider manual that "it is acceptable to use the ETC as an alternative to an ET tube for airway management in cardiac arrest." AHA also states, "This device (ETC) provides adequate ventilation comparable to an ET tube." The AHA also has similar statements regarding the LMA. Regardless of your agreement to the AHA, many people tend to follow and advocate AHA recommendations. I am not saying that the trend is a good one; however, this is the way things are moving. Heck, in my state, first responders are allowed to place LMA's and ETC's. In spite of our personal views, many people who have the power to institute policy seem to advocate this approach to airway management. In addition, there is allot of data that supports the use of "alternative airways." I attended an airway conference in the last year and a well known flight company medical director drafted and put into place an RSA (Rapid Sequence Airway) protocol that has been used. In essence, you administer the same meds as an RSI, but opt to place an "alternative airway" in place of traditional tracheal intubation. So, in a sense AZCEP is correct with his points. This is a hot topic and I think it will only intensify. Take care, chbare.

I am not sure I agree that Etomidate alone should be the primary modality. True, Etomidate may produce favorable intubating conditions. RSI without a paralytic in my mind is suboptimal. You still have to worry about laryngeospasm and intact muscle movement/tone. This can set you up for serious problems. Remember the goal of RSI is to attain a high first attempt success rate. Without that addition of a paralytic, you are producing suboptimal conditions for first attempt success. (IMHO) In addition, giving subsequent doses of Etomidate is asking for adrenal suppression. While this is treatable in the hospital, it can be lethal and lead to many problems. I agree that you need to cautious with Midazolam when taking blood pressure into consideration. Take care, chbare.

Irme, you need to appreciate how the ETC functions. It is a supraglottic device. In most cases, the distal tube will be placed into the esophagus while the proximal portion occludes the upper airway. This in theory will only allow air to flow through the glottis. Sounds like the next best thing to sliced bread (shameless cliche). However, lets throw in laryngeospasm, angioedema, an airway burn, or perhaps a COPD patient with high peak airway pressures. I hope you will be able to appreciate the pit-falls of the ETC. While it may work for most of our patients, many patients will require a cuffed tube in the trachea. With that said, the concept of "I will never miss the tube because I am excellent at intubation" is great in theory; however, reality dictates we plan for the worst. We must realize that in some cases, no amount of skill will produce the intended outcome. The ETC is a rescue device and should be utilized as such. Take care, chbare.

I understand all of the disadvantages of the LMA; however, you cannot deny that the LMA has advantages as well. Unfortunately, the research that I have seen regarding these two devices is all over the place. I think it would be hard to conclude that one device is definitively superior to another. Both devices have advantages and disadvantages. One has to remember why we are using these devices. We are placing these devices to rescue us from an ominous situation. We are essentially one step away from cutting flesh when we choose to insert these airways. Most would agree that both airways will function well as rescue devices. I think it really comes down to personal preference and experience when we look at these devices. I have yet to find highly definitive evidence one way or the other. I would hate to condemn the use of the LMA based on personal preference. With that, I have seen both devices function well in the rescue airway setting. I would agree that the King will most likely prove to be one of the best supraglottic devices available. The new King LTS has a gastric port that allows for GI decompression. I think this feature will only improve on a great design. However, my answer was based on the assumption that the person does not have access to the King and must choose between the ETC or LMA. Take care, chbare.

In that case, you may give greater consideration to the ETC. Population dependant. However, the LMA does offer some unique advantages: -The design will protect the glottis and lungs from aspiration of upper airway matter. -The LMA is easy to insert. -The LMA can be inserted with minimal spinal or head movement. -The LMA is available in many sizes. -The LMA comes in many different styles; *ILMA-allows the provider to attempt ETI. *LMA Proseal-uses a gastric tube for GI decompression. I believe it will tolerate airway pressures up to 30. This is comparable to the ETC. *LMA flexible-flexible tube allows placement in unique surgical conditions. *Classic LMA-is reusable and can be cleaned and autoclaved. *Newer LMA's with fiber optic viewing technology. Take care, chbare.

I wish I could say this suprises me; however, it looks like yet another in a long line of cases that share a common theme. I am glad there are people willing to expose the truth. This is actually quite sad. Many people are effected by these imposters. Take care, chbare.

Every device has it's good and bad aspects. I think the key is to choose a device or devices and know learn how to use it/them effectively. With that said, I would have to go with the LMA as well. This is due to the fact that LMA's come in sizes that cover nearly every age. Otherwise, ETC's are an effective device for the adult population. Take care, chbare.