chbare

Glutamic acid GABA Aspartic acid Vasopressin Somatostatin Neurotensin Acetylcholine Dopamine Serotonin Nitric Oxide Multiple aditional neurotransmitters Multiple additional neuropeptides Multiple additional electrolytes, solutes, and a solvent A few other substances thrown in for kicks. This is what I carry in my drug box. Take care, chbare.

Scratrat, beta blockers are generally not used in cocaine induced cardiac ischemia/injury. Vasospasm is a concern with the cocaine MI patient and beta blockers may block your beta receptors and allow for an unopposed alpha response. Unfortunately, arterial constriction is controlled via alpha receptors, and this may lead to worsened coronary vasospasm. Take care, chbare.

Ridryder911 and Ventmedic, +5. Take care, chbare.

I am not sure about midazolam and blood pressure. I used versed on nearly every ER intubation and noted decreases in blood pressure. I have rarely noted any hemodynamic changes other than increased heart rate with etomidate. Etomidate is now the only med I can use for RSI, so I have been able to use both meds on similar patients. I was able to easily find research that indicates hemodynamic changes occur with versed. http://emj.bmj.com/cgi/content/full/21/6/700 I do agree however, that comfort level is a major factor in what makes us decide to choose one medication over another. Take care, chbare.

Steven, I think there is more to this story. You sound like you are distracted, unable to focus, and having problems with self confidence. I suspect that you have allot on your plate and possibly some personal issues. I understand your desire to complete paramedic school; however, you may consider dealing will all of your other distractions and get yourself in a stable position. I have always been an advocate of education over experience when it comes to EMS; however, you may want to consider slowing down a little and getting into a comfort zone with your new job and possibly other things prior to tackling paramedic school. I think once you have a clear head and feel more confident, you will find your studies will be much easier. In addition, take a little time to decide if EMS is really your calling. I am not trying to be negative; however, EMS is not for everybody, and people are much more content when they work a job that they enjoy. Take care, chbare.

Firefighter523, I do think I understand your statements. I also think that perhaps communication broke down within the posts of this thread. In reviewing your posts I believe that you were trying to emphasize that you felt cardioversion on this patient was the proper treatment; however, in a round about way we ended up in a brawl. However, some of your statements were misleading. While, unconscious patients ability to hear was not a point of this thread, this among a few other concepts were thrown out none the less. Some of your language could be interpreted as aggressive and some of the statements were not correct. (I do think you were trying to make a point, it just came out wrong.) Please believe me when I say I am not attacking you or calling you names. I think things got a little aggressive in the heat of the moment. Sometimes we have to accept that we may have been a little erroneous in the delivery of our information,acknowledge and accept that fact, and move on with life. In some of my posts I have fudged on the delivery of my point, somebody called me on it, I acknowledge my error, and life continued. Take care, chbare.

I am having a hard time figuring this one out. "You should NOT let them decide, that is what you are there for. You are the professional, and are the one that is supposed to know what to do." I understand this goes against what many of us as medical providers believe; however, if a person is awake, oriented, and can communicate their wishes, you cannot perform care without consent. We do not make decisions for people. We do our best to educate and inform people and let them make the decision. Yes, in some cases a patient may undergo treatment against their wishes. This is usually done under a court order or in a protective custody type situation. I also understand that in some cases implied consent will apply. However, even in a critical patient, you could be charged with battery if they are awake, oriented, and refuse treatment, and you perform treatment against their wishes. In addition, you may face a civil suit in addition to criminal charges. I understand that this is frustrating; however, many civil and criminal cases have been successful against providers who touch or perform procedures on a patient against their wishes. In addition, it is well known that unconscious people can hear, feel, and have awareness of their environment. Mounds of data exist to back up this well known fact. Case reports from the patient in the OR, to the intubated sedated ICU patient, to the unresponsive brain bleed ER patient exist. With that said, the whole debate regarding consent is not the point of the case study. As I understand, we are talking about what type of treatment to consider for the patient in this threads case study. Take care, chbare.

A "silver bullet" drug would be a nice. While we are on this topic, has anybody seen any research on the use of the new alpha 2 blockers as a single agent med for intubation? I heard of talk about the potential for these meds as single agents for intubation at an airway confrence in 2005; however, I have yet to hear anything definitive. I could touch up on my Google-fu, but I figured I would pose this question in any event. Take care, chbare.

Zzyzx, you can give Amiodarone IVP as well. Granted, in the stable pt it will be a very slow push. Amiodarone is also taken PO by patients on chronic therapy. Take care, chbare.

DwayneEMTB, you pose an interesting question. First, nurses were able to recognize problems and band together in powerful and unified groups. These groups put aside petty differences and worked together toward collective goals that helped nursing as a profession. (note the emphasis on group work and not I, me, myself, or the many versions of the "to be verb.") At this point allot of people in EMS refuse to agree on what color of cool guy bag to put in the ambulance let alone uniting and pushing ideals that may actually help EMS transition into a profession. I may anger some people; however, this is the truth. We must unite and agree on what coarse to take before we can even consider planning or implementing our thoughts. Next, nursing realized that the road would be long, rough, and have many turns. Modern Nursing has been several decades in the making and dedicated people have been at the forefront to see it through. In EMS we must dedicate our selves to improvement and realize the process will be a long, hard, and ever changing work in progress. In addition, Nursing has traditionally (over the last few decades) embraced higher education and research to further solidify the providers as professionals. I know that even AAS students are strongly encouraged to seek higher education. Nursing realizes that medicine is a massive animal and no one program of instruction will produce a competent provider. Rather, I see a basic program of instruction that provides a solid foundation to build upon. (Nursing School) Next, nursing school emphasizes the professional aspects of nursing and includes in depth courses on nursing history, professional development, critical thinking, and emphasizes the fact that medicine is multidisciplinary and emphasizes the nurses critical role in this system. Finally, nursing education does not focus on "shake and bake" medicine. Nursing focuses on a holistic care concept. You are taught that the human is a whole and complex being, and treating a person is complex and involves multiple individualized interventions. There is less emphasis on performing skills and more emphasis on understanding the person's physiological and psychological response to illness. The assumption is that many of the invasive skills are specific to specialty areas of nursing and can be learned upon gaining experience and further education in those areas. Core skills such as IV therapy, med admin, foley, NG intubation, wound care, etc are taught; however, the emphasis is still on the person. This is my take on how nursing managed to gain acceptance as a profession. I think EMS is at a critical junction and can choose to take the path of a profession, or choose the path of a skilled monkey. Unfortunately, I see some negative changes in many of the nursing programs. I see a lack of discipline and basic professional abilities in newly minted nurses. I also see a lack of basic competence in new grads. Take care, chbare.

Interesting discussion. I am happy that the ER Tech job is working out. The hospital is indeed a good environment to learn medicine. I think people really down play the fact that you actually get exposed to medicine across the life span and in many cases you are able to see the big picture and learn how health care as an animal functions. (From the field to discharge) In addition, I think allot of the RN versus EMT attitude is a little overdramatized. I think that general mutual respect exists and good nurses realize that this is indeed a team effort. I also like the fact that you have access to physicians, RT's, and other providers who can provide a multitude of information. I have come to respect the knowledge and abilities of a good RT. Even more so now that I am taking care of vented patients and making changes in the absence of a physician or RT. Take care, chbare.

Interesting read and rather nostalgic because I had similar feelings as a newly minted EMT-B just over 10 years ago. Not enough can be said about "following instructions well, perform skills quickly with quality, and anticipate their partner’s needs." While many people may find this insulting, it is true. This is how EMS works. As a new flight nurse, I am learning how important it is to know and accept your limitations as a provider. This is simply teamwork 101. I know when we go on a bad scene call, my role is more supportive because the medic usually takes over. I need to recognize my strengths and weaknesses and when the medic runs the show it is my job to act as his/her back bone and anticipate his/her needs and ensure that I can support my partner in any way possible. This is nothing against me as a provider, it is simply good team work. Not enough can be said about providing professional care and compassionate care. Patients really do judge us by how we act. I just flew a patient and we changed her whole outlook on the transfer by performing a small non medical task. My partner and I both knew that the weather was windy and cold and we had a few minute stretcher ride from the landing pad to the ER, so we covered her with our jackets to protect her from the wind. A small task just had big implications. Take care, chbare.

Mortality related to burns is related to two concepts. 1) The severity, size, and location of the burn. 2) presence of risk factors. (Age, infection, inhalation injury, illness, etc) A down and dirty assessment technique I learned was to take the %BSA burned (2nd-3rd degree) and add it to your patient's age. This will give you a down and dirty indication of the probability of the patient developing very serious complications as a result of the burns. This is pretty down and dirty and should always be taken into context to the risk factors. Take care, chbare.

AZCEP, good call. The original post does seem to indicate the finding was isolated to one ear. Take care, chbare.

Older contusions can take on a brown to tan color. I have seen postauricular bruising on many patients. This may indicate a fracture to the base of the skull. We must be careful; however, not to diagnose based on one sign. We have all seen simple facial injuries result in periorbital contusions. Take care, chbare.

I have to agree with many of the other people on this topic. We will never have a system that satisfies people. The expectations of the general public are in most cases outrageous and out of touch with reality. Many of this nations pampered citizens turn into primary sociopaths that care only about them selves when they get a cough. They bypass the family provider with the expectation of cart la blanch service at the local ER. Then, they become volent and aggressive when a doc fails to look down their throat within 5 minutes of presentation because the doc is tubing a four year old who was ejected from the bed of a pick up at 80 MPH. I worked for a hospital that advertised in a similar way. Yes, people were seen and triaged within a few minutes, then most were booted back out into the waiting room. We cannot expect a zero wait time, especially with people using the ER as their private clinic. In addition, you have overcrowded ER's with backed up admits and intubated patients taking up space in the hallway. This is in addition to stalled out medical/surgical units and ICU's that cannot accept admits because they are full. Unfortunately, I think many people would not even respond to a massive education campaign regarding health care, I could not even get parents to do something as simple as rotating tylenol and motrin for fever. (even after seeing and attempting to educate the family multiple times) Loose loose situation for all parties involved. Take care, chbare.

Travisxx, you could always consider nursing school, get a job as a new grad at the neighborhood clinic, and forget about the commute. Take care, chbare.

Yet one more long term problem to consider with amiodarone treatment, thyroid dysfunction. Amiodarone is actually similar in structure to thyroxine. I personally have had several patients develop serious reactions to amiodarone when used to treat "stable ventricular tachycardia." I have seen torsades to syncopal episodes, to severe refractory vomiting. I try to avoid amiodarone if possible; however, my feelings are based more on personal experience than sound EBM. Take care, chbare.

Allow me to pose a question for the simple sake of mental master... With what we know regarding the mechanisms of action of these two medications, are there situations where lido would be more beneficial and visa versa. Take care, chbare.

We must; however, consider the multiple well known problems associated with amiodarone. Problems such as, pulmonary toxicity, QT interval prolongation and Torsades, multiple medication interactions, and very long half life must be considered prior to amiodarone administration. Take care, chbare.

Comanche, why not take what we know about electrolytes and develop a lay person friendly course of instruction. We need not talk about the sodium potassium ATPase pump to educate people. Look at the general areas where these electrolytes are important. "Potassium is important for proper function of the heart. Here are common problems that lead to potassium imbalance and here are basic things for you as a parent to look for." I bet you could make a great presentation translating your knowledge into a parent friendly presentation. In addition, the ability to translate medicine into every day terms will help you take better care of your patients and possibly help alleviate anxiety and fear by helping people understand their problem. Take care, chbare,

Zzyzx, I do not follow you on this one. It is not hard to mix an amiodarone drip. In addition, if you are only a few minutes from the hospital you may only have enough time to get the slow IVP of amiodarone in prior to hanging the maintenance infusion, so you just saved your self time and energy going with amiodarone. A good question to as would be, "what situations would warrant the infusion of amiodarone and what situations would warrant the infusion of lidocaine?" Take care, chbare.

Zzyzx, you are correct. The AV node cannot block all of the multiple chaotic impulses from the atria and you develop a rapid ventricular response. This is why some people call this atrial fibrillation with rapid ventricular response. In other disorder such as, WPW and LGL, you have an accessory pathway that bypasses the AV node. Take care, chbare.

Arctic_myst, it sounds like you are talking about the King. The King looks to be a very promising rescue device; however, it still suffers from the same problem as all of the other rescue devices with the exception of the LMA Fastrach and a few others that allow for intubation. (When you use them to intubate the trachea) These devices seal the airway above the glottis. This is why we may call these devices supraglottic airway devices. Any subglottic pathology may render these devices useless. (obstruction, burns, trauma, spasm, neoplasm, etc.) I agree that they can help establish an emergency airway and I would even go as far as saying that in most patients you could get by using these devices as a primary airway management method; however, a tube in the trachea or through the neck will still provide the most secure airway and may be the only way of securing the airway with specific types of pathology. We cannot simply write off intubation and expect to use rescue devices as primary devices. (There is a growing number of people who think otherwise however.) The importance of having a well educated and properly trained airway provider who can use all airway tools to their advantage is the key. Those of you who have seen these airways fail and have had to tube around these devices or transition to a surgical option are well aware of the pitfalls of relying on a single airway management strategy. Take care, chbare.

Ridryder911, I agree with your assessment as well. The evidence and conclusions are pretty vague and lack specific details. This seems similar to a study that concluded patients taken into the hospital by ambulance were more prone to death, so EMS care caused people to die. :roll: Take care, chbare.