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Wendy, the best physicians I know are flexible and will change as contemporary methods that are evidence based appear on the scene. Also, we need to be careful about personal experience and equating "my" way to the only way. This is why all those numbers are so important. If something is effective, the results must be verified and reproduced. Unfortunately, one provider and their limited experience with something, often under limited or homogenous conditions does not count. This is why some physicians will take a concept that works for them but is novel to everybody else and publish a paper on it. After doing so, somebody may take interest and perhaps develop large studies that reproduce the original findings. Once this occurs and enough people get on board, a paradigm shift may occur. This is the power of the scientific method.

How do you define the lightweightness of fentanyl? For example, you give 1 mg of morphine to a patient, you would expect a certain effect. (Average expectation value.) However, give a milligram (Ten times what most people often give.) of fentanyl to a patient. You would probably have a very different effect.

Ketamine isn't exactly popular out of hospital in the United States now let alone ten years ago.

I agree for the most part and that is why I came back to point out when this occurred because things are quite different now.

Neither person said that they would aggressively administer fluids. Having large bore access is probably not a bad idea and can be used to resuscitate with blood products if required after arriving at a medical facility.

We often worry about how "dirty" morphine is and histamine release; however, the evidence is all over the place. Anecdotally, I tend to shy away from morphine; however, that is personal bias. I've actually seen several studies where the efficacy and side effects profile of both drugs are fairly equivalent. While I personally tend to use fentanyl, I cannot condemn Dwayne for considering morphine at this point. If hypotension and additional information pointed to altered haemodynamics, I would not support the use of morphine. A recent study abstract comparing the two agents in the prehospital environment: http://www.ncbi.nlm.nih.gov/m/pubmed/21689900/ However, the presence of hypotension was considered part of the exclusion criteria.

Slip him a note and hope it stops? Assuming this story is correct, you would be comfortable with this course of action. We have no idea how many others have passed this way. First responder or paramedic, these are still people who are putting hands on patients.

I think you know what you need to do if this is really the case.

You are likely to find some variability on this issue. I am not aware of any strict concensus on how best to treat. However, most would probably agree that sudden increases (8-9 mEq/L/d or more) can lead to demylenating problems. However, most people would probably agree on a regimen where you carefully increase serum Sodium by a couple to a few mEq/L over several hours to stop seizures then correct very slowly and cautiously from there. Edit: With this patient, I'd probably try to resuscitate with NS and take it from there.

No, it's a type of hybrid lighted stylette. The Bougie can be used like a stylette, but can also have additional uses such as tube exchanger, difficult intubation adjunct and even as a method of proper tube placement verification.

Sounds like a new and interesting opportunity. Best of luck. Come back and make us ashamed of our knowledge of medical imagining. I'm always up for some learning.

Absolutely Dwayne. It just felt like we were focusing more on all the neat ways to illicit a response as opposed to the broader picture. Additionally, let's say the hand falls on the head. What does that mean? Is that a definitive sign for us to intubate, push a med, drive faster? What are some of these things we talk about actually telling us?

With all the dropping hands onto faces and sternum rubs, I cannot help but to see the following, except substitute her with a person who may be unresponsive:

Not at all, but let us look at the big picture instead of isolated, faker litmus tests.

Is our goal to find personal satisfaction in sorting out fakers or are we interested in something a bit more important. Arm to face drop, eyelash reflexes and so on have little relevance IMHO. Can the patient breath, are they swallowing, are they managing their secretions? The ability to spontaneously protect the airway is probably much more important than writing down a "P" on the PCR. Food for thought anyway.

However, do large numbers of rookie nurses volunteer? What about rookie respiratory therapists, radio -graphic technologists, physician assistants, physicians or perfusionists? Unfortunately, it's an issue that is highly isolated to a specific group. Also, what kind of structure and clinical enhancement process is in place to ensure rookies are able to transition into seasoned providers at these services? Do they have strong continuing education requirements, proper preceptor programmes in place, robust QA/QI processes that function, dedicated mentoring and highly involved medical directors? Unfortunately, it's my intuition that many paid services don't have these in place let alone many volley services.

Promethazine can also potentiate some of the effects of morphine. Dwayne, no hard, fast rule here. As Zilla stated, both agents do a reasonable job. My personal bias is against promethazine due to some bad experiences; however, personal mileage will vary.

Spoken like a true professional, thanks Zilla!

It has a black box warning for paediatric respiratory depression (<2 yo) and one for serious tissue injury. Edit: Added "one" to differentiate the two warnings.

While chemically very different, both agents are often classified as first generation antihistamines. Both agents have similar histamine blocking effects. However, I am personally not as comfortable using promethazine because of it's side effects profile. It has also been black boxed in the United States. I have also had the unfortunate experience of seeing people develop rather serious dystonic reactions because of promethazine. My personal bias is for the use of diphenhydramine. In addition, I grew quite fond of using IV dimenhydrinate for nausea and vomiting when I worked overseas. I believe an oral form exists in the United States called Dramamine.

Dwayne it has similar effects to something that you may have run across in Afghanistan called Hextend. Hextend is simply hetastarch in a Ringer's lactate solution. The chemical differences are complex, but I'll give you the readers digest version: Haemaccel is a Urea linked gelatin molecule. Think boiled proteins. Hetastarch is a polysaccharide molecule. Think complex carbohydrates. They essentially do the same thing but have different metabolic pathways and side effect profiles. I believe anaphylactiod reactions are more common with gelatins.

Penthidine is also known as Demerol. Dwayne, you should be able to find all the information you want if you use meperidine or Demerol as the search name.

I am not sure this assessment in a vacuum would reassure me that a patient is adequately protecting their airway.

If you are in school, I'd focus on that for now. Education is somewhat of a great equaliser. While not always, education give you many more options and flexibility. Additionally, $2,700 for an ambulance is not unreasonable. I strongly suggest you have a good feel for what you are getting into prior to moving to another country. Also, I understand that money is apparently not an issue for you; however, if you are truly making that much money, you'd be a statistical outlier in the United States. If you are wanting to continue in EMS in the United States, you should expect a very different lifestyle as wages are significantly lower. In fact, I wasn't even making those kind of wages back when I was taking travel contracts in high need hospitals as a certified emergency nurse.

Never dealt with ingestion, cutaneous exposure however.