chbare

Freshmeat, Informed makes some good pocket guides. They make BLS and ALS guides. I like the "Emergency & Critical Care guide," try www.informedguides.com . Take care, chbare.

AZCEP, thank you for the questions, I checked with the medic to verify the answers. Two IV's were established upon arrival and the fluid bolus was started as soon as vascular access was established. The BGL was 110mg/dl. As far as the RSI, these were the meds that the ER doctor ordered. 10 mg of versed was given for sedation followed by 10 mg of vecronium. Thank you again for the questions and feedback. Take care, chbare.

32 year old male presented to the er by ambulance combative and agitated. Primary Assessment ; RR-42 labored, hr 180 narrow complex tachycardia on the monitor, skin pale and mottled, b/p-85/40 Sao2-88%. LOC-awake but incoherent swinging at er staff and thrashing in his bed. HEENT: normocephalic, PERL Pupils at 4 bilat, nose and throat unremarkable, CX; lungs diminished without adventitious sound through all lobes, ABD, soft, EXT, full ROM noted nail beds cyanotic, no evidence of trauma. PMHX; unknown. HPI; EMS reports possible meth overdose. TX; given 10mg Haldol IM initially, the paramedic working ER identified that the patients was not ventilating and perfusing adequately and recommends immediate RSI to the ER doc. RSI performed (10 midazolam & 10 vecronium given) Intubated with 7.5 ETT placement verified. After RSI Pt's HR increased to 190 b/p 80/p, pt cardioverted at 100j no response noted, given 150mg of amiadarone IV and cardioverted at 200j without response, given 150mg codarone repeat dose without response, cardioversion at 300j without response, pt remains pale and mottled with b/p 80/p, immediate unsynchronized shock given at 360j without response. Pt placed in head down feet up position and bolused with 2000ml NS without response, given 40 mg diltiazem IV, HR decreased to 150-160, diltiazem drip started and titrated up to 45 mg /hour, HR decreased to 120's B/P stabilized in the 110 systolic range, the diltiazem drip was eventually titrated down to 20mg per hour. Labs; Ck-336, BUN and Creat were elevated, UDS + Cocaine and Meth, Tryponin negative, all other labs were negative. Disposition; pt remained intubated and was admitted to the ICU. Please note, this case was written by a paramedic in our er who wanted somebody to review the ed treatment and provide suggestions/feedback regarding the care that this patient recieved. I appreciate you responses and will try to clarify any questions the best I can. Take care, chbare.

Michael, three words why you should not get it, Pennywise the Clown. He scared the poop out of me. Seriously, allot of people use this style of scope at my hospital and seem to like it. Take care, chbare.

I agree with the above posts. A solid foundation in A&P will be very helpful. You start in the fall, is there any chance of getting a semester of A&P in prior to starting school? In addition, a working knowledge of basic math and algebra should be helpful for med calculations. Take care, chbare.

MosaicNate, first, welcome to the city. Check out some of the forums and threads, you will find more answers and information than you thought possible. I cannot help you with one to one chat, I am not really much of a chatter. However, you could post specific questions/frustrations that you cannot answer with research and you may get an answer form someone. It also sounds like you are questioning your career path. There are many negative aspects to EMS. You must overcome or work around limited jobs, poor pay, dangerous and unstable environments, stress, and poor working hours. This is not to say that you cannot make a career out of EMS, many people have. I just want you to carefully consider the pros and cons of what you are getting into and make an informed decision about making a career out of EMS. I hope this helps. Take care, chbare.

They have it down to a science in my area. They will come to the er waiting room, do a recon, and find out how busy the er is before checking in or returning later. Another trick I see, is if they see people leaving during their recon the will ask and find out what doc is working. Then, you have the er is real busy and I am already checked in what to do trick. They simply leave the waiting room and call 911 with the hope that being strapped to a stretcher will get them in the back faster. I would say 70 % or more of what we see is non emergent. There is a saying that goes something like, ER doctors saving patients from their PMD's since the dawn of time. :roll: Take care, chbare.

I still do not understand the whole hypoxic drive thing. People still spout off "do not give COPD patients oxygen" like its dogma. Like MedicRN stated, you are looking at several hours to wipe out the patients drive. This thinking is still encountered in the hospital as well. I had a nurse take a NRB off of my patient because the patient had COPD. I put the NRB back on and told the nurse not to touch my patients without asking. I also told her you give patients oxygen if they need oxygen. If by some act of God they stop breathing 3 minutes into receiving high flow oxygen, I am sure I can figure out how to use that inflating bag thingy and a flexible nose tube thingy to breath for them. :roll: Take care, chbare.

Pacerman13170, nursing school is the only way to go. The dark side awaits. Good luck with paramedic school. Take care, chbare.

MissingLink, welcome to the city. These courses focus on law enforcement. The medical tactics are very similar to what the new CLS courses teach. Courses such as CONTOMS give you a taste of how to operate on a tactical unit. Lots of info on intelligence gathering and preparing the medical threat assessment. I guess this would be similar to an area study or the medical annex of an OPORDER tailored to the LE environment. Other schools such as Gunsite Tac Med, focus on shooting and personal weapon manipulation with some basic medical tactics thrown in. I do not think you could compare any of these courses to any of the 18 series MOS training. (I never held an 18 series MOS, so I really do not know, just a hypothesis.) Take care, chbare.

Delta waves? Any Hx. of WPW or LGL? Any other medical Hx? Drug abuse? Take care, chbare.

ERDoc, thank you, I greatly appreciate your input. I agree that there was very ominous pathophysiology occurring. The liver enzymes and alk phos were a little elevated, the BUN and Creat were normal, and the TSH was very elevated. Cardiac enzymes were negative. The rest of the patients electrolytes were normal. The APAP & ASA levels were not elevated. The patient had about 4 liters of total fluid in and about 2 liters of total fluid out while in the er. Take care, chbare.

ERDoc, I agree, the first ABG I wrote off as blowing off CO2. It is just strange that the C02 never really normalized or moved in that direction. Even the flight team was confused. The patients pressures remained in the 110 systolic range, but could that have been the neosynephrine drip hiding really poor cardiac output? AZCEP, I really do not know about antidepressant use. We knew the patient was on a beta blocker and antithyroid meds, and apparently quit taking meds per family. The whole drooling and lacrimation thing makes me question some kind of cholinergic toxidrome. Jeep_911, dont worry, I do not quite understand what was going on with this patient. Thank you for the replies. Take care, chbare.

Good afternoon. EMS brought a 23 year old patient to the er. Patient was found on the floor unresponsive by family. History of hyperthyroidism, PSVT, and depression. Initial assessment findings; very lethargic opens eyes and answers simple yes no commands with verbal command, pupils 5 and very sluggish, slight movement of all ext with command, pale diaphoretic skin and allot of salivation and lacrimation noted, patient was initially able to manage their own airway, P-70 and reg, B/P-80/50, RR-12-14 lungs clear upper bilat and diminished lower bilat, belly soft non tender, no indications of trauma noted, o2 Sat: 99% on NRB, Temp 95 F, ECG sinus rhythm with a 1 st degree AV block. I continued the oxygen and put the bed in a head down feet up position and started two IV's NS wide open. The ER doc came in the room and agreed to a 2000ml fluid bolus. In addition, I put a bair hugger blanket around the pt. Labs were drawn and and a 12 lead was obtained. The family stated the patient quit taking beta blockers and thyroid meds a while ago but did not know anything else, specific meds were unavailable, Pt denied taking any substances. A foley was inserted and ongoing assessments continued. The B/P did not improve with two liters of fluid and the pt remained pale, lethargic, and diaphoretic. A neosynephrine gtt was ordered, I mixed it and started at 40 micrograms/min and started a 3rd IV just in case. The pressure stabilized at around 100-110 systolic. Then X-ray entered the room and I helped him get the machine in position for a portable, suddenly the patient started throwing up. I rolled the patient on their side and started to suction, the patient continued to throw up and sats dropped to 89-90%. I continued to suction and call for help. The doctor decided to intubate and RSI meds were given. The patient was intubated with a 7.5 ETT and placement was verified. An NG was also placed. A chest X ray was performed and the patient was put on the vent (TV 750 PEEP 5 R 14 FIO2 100). An initial ABG showed PH 7.44 O2 144 CO2 18 Bicarb 22) the vent settings were changed (TV 700 PEEP 5 R 14 FIO2 80) Labs started rolling in UDS neg, H & H 6&18, K+ 2.1, WBC 18, ETOH 230, chest xray-good tube placement, infiltrates everywhere (not the acute aspiration looking stuff-it looks like the patient has been sick for a while), and a huge heart. The house supervisor started making calls for a transfer while I pushed meds and hung drips. We did a K run, 2 units of blood, and rocephin, I gave vec and fentanyl for sedation/paralysis. The flight team arrived and we package the patient for transport. The funny thing is the Et Co2 was about 17-19 and this was confirmed with ABGs. Did we blow it all off or poor cardiac out put? I just wanted to get your input on the case. This was a sick patient with allot of problems. Take care, chbare.

Field Medic, welcome to the city from a former 91B/91W. As a civilian you could look and see if the local PD or SO had tactical medic positions open. If you are still in the El Paso area, you could look at Las Cruces SO. You could also look at DOE in Albuquerque. Take care, chbare.

ERDoc, thank you for the scenario. Take care, chbare.

Is there a history of cardiomyopathy or heart failure? What does it say on the bottle? I am still confused as to why she would have been on milrinone for a head cyst. Any recent surgery? Consider a neoplasm with mets, pituitary tumor, intracranial pathology related to her accident, thrombosis, or medication/substance related. History of drug abuse and is she on any other medications? Take care, chbare.

Something does not add up. Milrinone for a cyst? We need to verify the accuracy of her history. Take care, chbare.

Ace844, I agree. I would never want to strictly define definitive care, this is a broad and simple way of understanding definitive care. I also agree that many er and ems treatments are the same. I do not want to simply say ems and er are not definitive care, because in situations they are, but rather say definitive care should be in context to the situation. Take care, chbare.

Hammerpcp, good thread. I remember the first time I had to place pads on an arrest patient. I just froze for a few seconds because I never practiced putting them on in my labs. Thank God for the little pictures. I agree that actually performing skills and procedures as opposed to verbalizing will ensure proper learning and utilization of them in a real situation. I remember a quote that somebody told me that really sums up the learning process. "You do not rise to the occasion in times of distress, you sink to the level of your training." When I helped with training for the National Guard we would set up scenarios similar to what Ridryder 911 suggested. We had a dummy that would accept ECG electrodes and pads, and you could intubate it and perform CPR. We also had a life pack 10, rhythm generator, and a drug box with outdated syringes and vials of meds that we would refill with water after use. In addition, we had an IV arm and IV equipment and an IV that would run into a empty gallon jug for pushing meds and flow rate calculation. We also had airway management equipment and et CO2 detectors. We would set everything up and have the students break into small groups. Out side of the building they would get a scenario and begin from there. They would bring in all of their equipment and start the scenario like any real patient contact. They would have to actually perform assessments and procedures in real time. In addition they had to document the entire code on a SF-600, (Military medical record) and document like the form was going into the patients actual medical record. All of the students liked the added stress and realism. I also agree that nothing can substitute good clinical experiences. Take care, chbare.

PRPGfirerescuetech, I would define definitive care as medical care that will help cure or improve your patients condition rather than stabilization or buying time. Take care, chbare.

"As a side note, we are equal opportunity bashers here. Medics suck, EMT's suck, american EMS sucks, and were all looking for housing and jobs in Canada. Any other questions? " Now that is funny! Take care, chbare.

PRPGfirerescuetech, I guess it depends on the situation and how definitive care is defined for the situation. I do not think you could even consider the er definitive care for many conditions. Take care, chbare.

Smle, not a big deal. It sounds like you may have had a bad experience and were blowing off some steam? I understand what you are saying, I have ran into incompetence at every level in the health care system, and while I have my thoughts regarding education and skill/procedure levels of EMT-B's & EMT-I's, there is no excuse for me treating these people poorly while at work. I think you will find that people on this site are not against EMT-B's. Most of the people are simply advocating better education for both EMT-B's & paramedics. Take care, chbare.

JPINFV, I got you and that makes sense, being that hydrogen becomes an ion once absorbed by the body. AZCEP, I agree I love cellular physiology. Everything we do at a macroscopic level, (IV, meds, Ventilation, Defib, etc) will ultimately cause changes at the cellular level. Take care, chbare.