chbare

Spock, our hospital does not have a protocol for intubating burn patients. We will usually intubate any burn pt suspected of having respiratory injury early. We generally use a 7.0-8.0 on an adult. In addition our docs like to use vec over sux in the burn patients, even prior to the 24 hour fluid shift period. (just to play it safe) Our county only has 2 paramedics that work EMS. (all BLS & ILS) All the other medics work for the hospital or the transport service, so we do not get allot of intubated patients from the field. In addition paramedics cannot RSI in the field without a special skill designation in our area, so we get patients that should be intubated, but the medics opt out of intubation because the patients are awake and have intact gag reflexes. I can only guess that the medic grabbed the wrong tube in the chaos of the situation, or decided to be very conservative because of the airway edema. Take care, chbare.

I think I am still in denial about living in a desert. Take care, chbare.

Danb, Welcome to the city. There are several threads that discuss the merits of various EMS agencies. You may find it hard to make a career as an EMT-B. (low pay & limited job opportunities) If you have the means, get into college and get a degree in medicine. (Paramedic, Nursing, RT, etc) Take care, chbare.

Hammerpcp, I have had a few bad experiences with sycopal episodes and low BGL's, I admit I am a little overzealous about BGL's, but we all cannot be without vices. Did anybody try for an EJ? do we have IO access as an option If she crashes while attempting EJ access? Too bad we could not do a quick US and look for fluid/aneurysm. Sorry, I overlooked the no pulsating masses part of your assessment, typical nurse not listening to the medic. Take care, chbare.

Aneurysm until proven otherwise, as of now. Pulsatile abdominal mass? Does her voice sound hoarse? Do the lower extremities appear mottled or cyanotic? BGL? I would want to be very judicious about IV fluids. Take care, chbare.

ERDoc, you are not the only doc that thinks this way. Very few of our ER docs would have used lidocaine in this situation. medic53226, I am not a doc but I would have used lidocaine. I have had several patients develop bad reactions to amiadarone. Nothing scientific or research based, but I have had better outcomes with lidocaine. I like the fact that lidocaine has a much shorter half life and it seems like every patient that gets converted with amiadarone becomes a life long user. Just my opinion however. Take care, chbare.

here is a link to a diagram describing the clotting cascade. It is a pretty complex process and you can see that several substances are involved. In addition to all of the factors and substances calcium plays a crucial role in clotting. I hope this helps with regard to what factor works where. http://www.hallym.or.kr/~kdcp/hematol/Coag-cascade.htm Take care, chbare.

Fire_911medic, Factor VIII is a naturally produced clotting factor in the clotting cascade. It is needed to complete the clotting process. However, like Dustdevil stated giving it to a trauma patient in the absence of a bleeding disorder could cause serious problems. The most commonly talked about disorder where people receive clotting factor VIII is Hemophilia A. (factor VIII deficiency) Here is a link to some basic information on Hemophilia A, you can also use this site to look up other types of Hemophilia. http://www.hemophilia.org/NHFWeb/MainPgs/M...ptname=bleeding Take care, chbare.

Fire_911medic, if she had a bleeding disorder they may have given her recombinant factor 8 or recombinant factor 9. She may have received vitamin K if there was a coagulopathy that could be reversed with Vit K. She may have also received fresh frozen plasma (contains clotting factors) or cryoprecipitate, depending on her condition and what she would allow. Products such as Hextend (Hetastarch and LR) and Hespan (Hetastarch) are colloids, but do not contain clotting factors and cannot transport oxygen. Hetastarch is a large molecule that exerts allot of osmotic pressure that causes water to shift into the vascular space. The old Rob peter to pay Paul analogy. Unlike crystalloids that will rapidly diffuse out of the vascular space, ( about 2/3 in 1 hour when you talk about NS and LR ) colloids are heavy and tend to stay in the vascular space much longer. However, colloids are not without complications and are not a magic bullet for blood loss. I hope this helps. Take care, chbare.

Good thread, I agree with you ERDoc. I have seen some people who say if feels like a numb pins and needles sensation, while others howl in pain. We had a cardiologist who would wheel in his little machine and put an external device directly on the Chest wall above the AICD. It was pretty neat to see, he could call up the devices history and even change the device settings. All of the nurses hated this doc because he was rude and arrogant, but he provided top notch care and he was excellent with his patients. The first transvenous pacemaker placement that I saw was performed by his hands. I grew to really like him, sure we threw some french duologue at one and other, but he was a top notch doc and would take the time to teach and explain things if you asked. Too bad he moved. I hear he is in ERDocs neck of the woods. TechMedic05, I imagine life span is pretty variable, but i have been told that most pacemaker type devices have a general life of 5-10 years. Here is a good article about pacemakers and AICD's. http://www.emedicine.com/emerg/topic805.htm Take care, chbare.

Krj00, I do not think it is lack of interest, I believe that people are interested and have weighed in on the other threads. I am holding off judgment until all of the trials are finished and all of the facts surrounding polyheme are published. We in medicine have this bad habit of looking at the newest and greatest thing as a magic bullet. Disease is remarkable at adapting to all of our latest and greatest technology. Just look at PCN. I will wait and see just how effective polyheme is. I am skeptical and anything short of a trauma surgeon in a 2 ML vial for injection may not be very helpful for that guy who is bleeding out from internal vascular insult, or perhaps it will be a great stop gap treatment to buy that guy some time. I guess we will see. Take care, chbare.

FishHawk, check the Colorado state EMS office on line. www.cdphe.state.co.us/em/PCPStatuteRule.asp. Click on statues and rules and then click on Colorado EMTS act. It looks like you can find every Colorado law on that link. Take care, chbare.

ERDoc, thanks again for your scenarios. They definitely require critical thinking and spark good conversation. Take care, chbare.

Krj00, take a look at some of the other threads. There are a couple of good threads on Polyheme and some debate on how people are running the trials. Take care, chbare.

I agree, everybody is correct, beta blockers will cause more harm than good. Uncontrolled alpha stimulation and worsened vessel spasm leading to worsened ischemia and damage. The esmolol thing would be more of an act of desperation, and I do not think we are even close to that point with this patient. In addition I believe the esmolol would be given with nitroprusside. Sorry about that. Take care, chbare.

Vs-eh?, I do not know if allot of US paramedic programs have a dedicated pharmacology course as a part of their program. It sounded like the paramedic programs that the instructors were talking about had a pharmacology portion, but it was integrated into the core paramedic course. The instructors designed a separate dedicated pharmacology course. Then, the students would be exposed to pharmacology again while taking the core paramedic curriculum. This is a 2 year course, so the medic students would have to complete a number of separate college level courses in addition to the paramedic portion of the program. Take care, chbare.

This is just a side note and not intended to hijack the thread or bring up the whole RN versus Paramedic thing. I had the pleasure of talking with a couple of paramedic instructors that have nearly finished the curriculum development for a 2 year paramedic program. They both have masters degrees with education background and many years of paramedic field experience, so I think they are defiantly qualified as instructors. They told me that allot of medic schools focus on just the drugs that medics commonly give. These instructors audited several nursing courses and found that they really liked how the nurses had to take a dedicated pharmacology course and cover a broad range of medications and physiology. The instructors have designed a pharmacology course similar to what they went through. The instructors thought that covering a broad range of meds and disorders that these meds are used for, in addition to more in depth physiology and A&P requirements for the AS degree would better prepare the paramedics as opposed to teaching a "cook book" list of medications. Take care, chbare.

Freshmeat, have you considered a medical drop pouch? It is smaller than a pack and would be out of the way on your leg. Blackhawk and several other dealers make drop pouches. Take care, chbare.

AZCEP, I agree with the use of ASA and Nitro. Nitro has been used with success to counteract cocaine induced vasoconstriction. I believe an alpha blocker such as phentolamine is the next choice for treatment if Nitro and judicious use of benzos do not help. I would consider beta blockers if the primary treatments fail. I think the use of a selective B1 blocker such as esmolol may be considered as a last line drug. Take care, chbare.

I agree with everybody that a 12 lead is in order. We need to quickly find out if he is having myocardial ischemia or injury. I suspect he is. I have seen a few young healthy people have MI's from cocaine use. His pressure is elevated and I agree with nitro and ASA if no contraindications exist. I also will consider beta blockers especially if nitrates do not help with the elevated pressure. Any other pertinent past history or allergies? Take care, chbare.

Freshmeat, your profile states that you are a contractor. Is the EMT job related to a contract? I have a small Blackhawk range bag that I use as a crash kit. If this is relevant to your practice I can post pics of how it is set up. It is a little larger than a fanny pack, but you can easily throw it over your shoulder. Take care, chbare.

MedicDude, you should not have a problem. I work three to four twelve hour shifts a week and manage to work out 5-6 times a week. I work nights, (7-7) so I find it is best to work out first thing in the morning after getting off or shortly after waking up in the afternoon. I find working out actually makes me feel better and I look forward to going out for a run or to the gym while I am working. Take care, chbare.

ERDoc, are labs, (CBC,CMP,PT,PTT,INR,T&S) Xray, venous Doppler ultrasound, and CT available, or should I be focusing on a better physical exam? Consider IV beta blockers for the elevated B/P. Take care, chbare.

ERDoc, LOC?, V/S?, supplemental O2, and cardiac monitor with a 12 lead if possible. Any history of drug use or ingestion of OTC meds/herbal supplements? Can he describe the pain? Lung sounds? Associated S/S? (N/V, Abd pain, dyspnea) Take care, chabre.

Elevated B/P and back pain with Hx of HTN and S/P MVC raises flags regarding complications from an aneurysm (hence the questions), however, I cannot rule out a possible vascular obstruction at this point in time. I opt for hasty transport and initiating 2 lines at TKO with continued freq V/S monitoring, O2 therapy, and continuous cardiac telemetry. Progressive EMS?? Take care, chbare.