chbare

Grandma is not home; however, you gather it is some kind of cough or cold medication from the older brother's comments. The patient suddenly begins to seize. You note generalized tonic clonic activity. Take care, chbare.

The patient still has an intact gag reflex and does not accept an OPA. Airway positioning, suction, and high flow O2 is applied. The snoring resolves with positioning, and the respiratory rate remains ten breaths per minute. Pupils are equal, round, and slightly sluggish to react bilat. He has a carotid heart rate of 50, and it feels slightly irregular. The monitor shows sinus bradycardia with a first degree AV block and an occasional unifocal PVC. No toxins or medications in the house. The brother is able to tell you that the patient took some pills when they visited grandma about an hour ago. The parents seem frightened and genuinely fearful for their son. Take care, chbare.

No signs of trauma. Patient has slow snoring respirations at a rate of ten. Parents speak little english; however, you gather that the patient may have taken something. Take care, chbare.

You arrive on scene and observe a 21 month old male in his mothers arms. The patient appears pale and is very lethargic. He only responds to painful stimuli. The parents are crying and the patients 8 year old brother is in a corner looking guilty about something. Take care, chbare.

You are called to the scene of a 21 month old. Dispatch reports a complaint of "not acting normally." What would you like to know? Take care, chbare.

JCicco345, there indeed many PDA's on the market. Prices are variable from about $100.00 to over $1,000.00. Honestly assess your needs and your financial limit, then decide on what type of capabilities are mandatory, and what capabilities you can live without. A good basic level platform is the Palm Z22. You can buy one for around $100.00. It will allow you to run most of the basic Palm OS software (Epocrates, Medical Wizards, etc) and beam information to other Palm OS devices. It also has limited photo and graphics abilities. The Z22 is small, has good battery life, and I think you get a good entry level platform for your money. However, the Z22 has limited memory. (About 5MB) In addition, you cannot run MP3 files or utilize a memory card expansion to increase your memory. The Z22 does not have Bluetooth or WIFI technology. The Palm Tungsten E2 may be a good option if you are willing to spend around $200.00. The E2 has about 64 MB of memory, accepts a memory card (SD), has Bluetooth technology, conversion software for Windows programs (Word, Powerpoint, etc), MP3 capabilities, and for about $100.00 you can buy a WIFI card and have the internet access at hotspots. The $300.00 Palm T/X will give you built in WIFI and a very large screen. My Wife uses T/X because she does not have to don reading glasses to use the device. Poor battery performance seems to be a problem with this device however. Many Windows based devices are now on the market and they have variable price ranges. Dell markets several well known models of PDA's. Many people are going the Windows OS route and prefer to use the familiar Windows interface. Many people have jumped on the "Smart Phone" wagon. This seems to be a sound concept because you can combine a PDA and a phone. This allows you to perform a variety of tasks with one device. Many models exist that have both Palm and Windows operating systems. The Treo smart phones seem to be very popular. The lower end Treos have Palm OS (600 & 650), while the higher end devices utilize a Windows OS (700 series). Price range is variable; however, you may be able to work a nice deal with a cell service provider. (Verizon, Alltel, etc) In addition, other devices such as the BlackJack exist. In the end, it comes down to you. You need to do a little research and choose a platform that will fit into your budget and provide all of your needs. Take care, chbare.

Thank you for the clarification. I see Dustdevil put that as the MOS as well. I herd that they were looking at instituting changes prior to my ETS date in April 2006. Our state was still trying to transition medics into the 91W MOS. This is the reason I picked up my NREMT-I. Is the core program still the same 16 week course, or have they instituted major changes to the curriculum? I guess I will find out in the next year in any event. I put in a packet for a commission into the ANC after my ETS date and I am currently waiting for fed rec. Take care, chbare.

The ResQshop software is very comprehensive and covers many different areas. If you provide CCT, you will like the ventilator and acid base calculators. Take care, chbare.

Medic is indeed a pretty generic term when you talk about the military. Several medical MOS's exist. In the Army, the entry level medical MOS could be considered the 91W. (health care specialist on the enlisted side) I would consider the 91W to be one of the chief backbone medical providers in the Army. However, you also have several other medical MOS's such as, Nurses, PA's, Medical Service Corp officers, Doctors, Vets, and many other skilled technical medical MOS's. To muddy the water, you have your special operations medical providers, combat life savers, and something called an additional skill identifier. (ASI) For example, a 91W may complete the Army LPN program and have the ASI M6. They are still considered a medic; however, they have additional education and credentials as an LPN and may work in that role. (91WM6) Take care, chbare.

EDIT: Double post, I apologize. Take care, chbare.

Interesting, still using a first generation cephalosporin in the field? Take care, chbare.

AZCEP, I agree. After thinking about this for a while, I can see how somebody can easily get confused even with the basic concepts of hemodynamics. Take care, chbare.

Pro_EMT, I suspect that many services choose not to use the LMA because the LMA has many pitfalls. They include: -Easily dislodged: The LMA is easily dislodged and requires constant attention, something that is difficult to achieve at best in the pre-hospital environment. -Low pressure seal around the glottic opening: The LMA provides little aspiration protection. -Low airway pressures: With peak pressures above 20 cm/H20, air will bypass the seal and enter the gut. This further increases the risk of aspiration. The design of the Combitube seems to be a little more favorable in the pre-hospital environment because you can ventilate with slightly higher airway pressures, it provides additional aspiration protection, and the self seating action of the proximal cuff makes the ETC less prone to dislodgment. While I actually like the LMA and agree that it has definite advantages in the controlled setting of the OR where you have a fasting patient, I would urge you to do a little more research and consider some of the pitfalls of using the LMA. Take care, chbare.

Actually preload can apply to both the ventricle and atrium. We most often associate preload with the left ventricle; however, the technical definition of preload is the sarcomere stretch just prior to a heart chamber contraction. It seems there are a few different schools of thought regarding preload. The following link explains my point of view and education regarding preload. http://www.cvphysiology.com/Cardiac%20Function/CF007.htm Take care, chbare.

Chris, what about these concepts are you having difficulty understanding? Is it simply confusing the two, or is the entire concept foreign? Preload is basically the amount of pressure in the left ventricle following atrial contraction. Hence the term "atrial kick." Preload is related to two mechanisms. 1; the pressure and venous return from the body and 2; a properly functioning right ventricle. Since preload is dependant upon venous return, conditions that cause low venous pressure will reduce preload. (hypovolemia and loss of venous tone) Preload is an important part of cardiac output, because the stretch of the ventricle caused by preload helps to increase the pumping action and total amount of blood pumped by the left ventricle. This is often called "Starlings Law of the Heart." Afterload is basically the amount of pressure the left ventricle must overcome to open the aortic valve and pump blood to the body. In the absence of all other factors, increased afterload will cause decreased cardiac output. So, to keep from confusing the two, you can look at preload as being related to the venous system and afterload as being related to the arterial system. A very basic generalization; however, it may help to differentiate between these two concepts. I hope this helps. Take care, chbare.

I am not sure that being male is a significant factor. It take the cooperation of two people. In addition, I have seen the devastating effects of infidelity in the female dominated world of nursing. Take care, chbare.

Infidelity is rampant throughout the US and many other countries I suspect. A general lack of respect, maturity, and impulse control seem to be primary factors. Pretty sad state of affairs. Take care, chbare.

Still a difficult discussion. I have posted a link to a report from the Committee Tactical Combat Casualty Care. While this does not equate to civilian medicine, some of the situations may have similarities to the situation at hand. The discussion regarding ABO therapy starts on page 14. In addition, this information is a few years old and the world of medications is ever changing. What are the surgeon's thoughts on this subject? http://phtls.org/datafiles/military5th2003sept04.pdf Take care, chbare.

I think a comprehensive nationally recognized standard of education is needed. A college would need be accredited to teach the curriculum and the minimal requirements of graduation would be required for every other program. This would ensure that everybody is on the same page and has a common foundation upon graduation. I think scope of practice could be similar to RN scope of practice. The state and institutions would still have the ability to customize scope of practice, much like nursing. However, the foundation of education would still remain standardized. Take care, chbare.

Spock, thank you for the correction. I had 10% in my head, and this was obviously incorrect. Tniuqs, what kind of critter bites are most commonly encountered? For example, cat bites are more prone to infection with the microbe Pasteurella multocida. (Early wound infection that is) Cats will inflict more puncture wounds while dogs inflict crush and laceration type wounds. So, you can appreciate the difference from animal to animal. As I recall cat bites are more prone to infection, and I bet this is related to the puncture mechanism. Wound care is a pretty heated topic. Agents such as hydrogen peroxide and iodine based solutions have antimicrobial activity; however, I have seen many docs quit using these agents because they are toxic to healthy tissue and may cause delayed healing. I think most people could agree that aggressive irrigation of a contaminated wound with sterile saline would be helpful. Forced irrigation with copious amounts of saline wound help remove gross contamination. I have seen people use mild soap and hibicleanse solutions as well. For superficial abrasions and road rash like wounds, I have used a mild solution of soapy water and a hand brush to cleanse gross contamination. (I use the same type of brush that surgeons utilize for hand washing) Following the scrub, I will aggressively irrigate with saline and then assess the wound for devitalized tissue and additional foreign body contamination. Deep puncture wounds and abdominal wounds that could involve communication with internal structures really need surgical evaluation. Puncture wounds like the one you described could receive aggressive irrigation and the application of a sterile dressing. Of course this is all secondary to hemostasis. In addition, the equipment required and time required would also be a factor. I would also argue that attempting to provide involved wound care in a helicopter enroute to definitive care may have limited benefits versus the hassle of additional resources and access problems while on the helo. Try to find a wound care specialist or certified wound care nurse for additional information. This is really a specialized area of medicine. Take care, chbare. EDIT: I just saw Ridryder911's post and agree that having the surgeon involved may lead to better results.

Spock, your response relates well to the education threads. Without more post graduate and PhD educated providers we cannot hope to have EMS based and EMS specific research. In addition, post graduate and PhD progams that are EMS specific would ensure that we continue to have EMS research and stay in the game of EMB. Take care, chbare.

If the hospital has an actual position for you, an official "job description" should exist. This document should describe what is required and expected of you. If the hospital does not have a job description for your job title and cannot put in writing your scope of practice, then listen to Ruffems and look for employment elsewhere. Take care, chbare.

Ridryder911, I tend to agree with your points. I agree that ABO therapy has a place; however, we must be careful when considering how and when to employ broad spectrum agents. I think it could be considered in the unique situation of delayed evac. I am talking greater than 8 hours. In addition, if you have evac times that exceed 24 hours, I think that more involved wound care could add to improved outcomes. Tnigus, this is what I was contemplating. Why we are waiting for evac, we can use those several hours to perform aggressive irrigation and possible debridement of soft tissue injuries that can be managed in such a way. You can use the time to identify devitalized tissue areas and possibly obtain a wound culture if infection is suspected. However, I could be reading this wrong. Are you on scene with a patient for several hours waiting for evac, or are you picking up patients that received their injuries several hours ago and transporting them to definitive care. If the later is the case, then I apologize, as I would agree with Ridryder911 that the limited amount of time during transport would really limit your ability to provide effective wound care. Then, perhaps a wide spread campaign of education and preventative medicine organized by your service could help with teaching people about these kinds of injuries and also assist with developing rapport with your clients. In any event, the decision to use antimicrobials in the field should be a well thought out plan. There are many potential problems to consider when administering ABO's. Not only are we talking about MRSA & VRE, but approx 10% of people (do not quote me) with an allergy to PCN will have a cross reaction to cephalosporins. This among many other problems must be considered. Take care, chbare. PS, sorry for the typos. I have not developed the skill of "Treo Typing."

I think you took my comment out of context. Hitting somebody with a 3rd gen cephalosporin is shotgunning. Broad spectrum activity. I did not disagree with ABO coverage in the presence of delayed evac. In fact, I had to cover patients with ABO therapy because of a similar situation when I was deployed following Katrina. Does your service have aggressive wound management guidelines for such situations? Take care, chbare.

The good old shotgun approach, something to consider in special situations. What is your medical directors stance? I would be cautious about shotgunning all types of injuries that have delayed evac with a 3rd gen cephalosporin. For example, some types of animal bites are best treated with Augmentin. However, still something to consider in some situations. Take care, chbare