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Sihi, I appreciate your involvement with this discussion. However, you provide little evidence to support your stance with the exception of a n=1 case study. The topic of paralytics is not as easy to debate as some would think. This is especially true when we consider what occurs outside of the hospital in some countries. Attached is what I believe to be a good link where two physicians debate this topic as it relates to in-hospital intubations. Additionally, new evidence is utilised. http://emcrit.org/podcasts/paralytics-for-icu-intubations/ Unfortunately, I am not aware of a significant body of literature regarding the pre-hospital provider. At this time I have to error on the side of the traditional approach and perhaps more conservative option of using a paralytic. Of course, I admit that I have a bias against pre-hospital intubation in general and the context of my point is based on pre-hospital care and literature within the United States.

The concern with intubation is it's relatively slow onset and potential haemodynamic issues. Another consideration is under dosing. I find many providers are not keen to give more than 5 mg when you will need to give least 0.1-0.3 mg/kg IV ( some will even say 0.4 mg/kg) for a good induction dose. When was the last time you slammed your 70 kg patient with 20+ mg of midazolam? Also, you will need to wait 2-3 minutes following an induction dose of midazolam prior to administering your paralytic. This only increases the chances of desaturation. I thought we addressed your concerns about midazolam in great detail on the other thread. Using midazolam as an induction agent is very different than as an anti-seizure medication. Apples to oranges comparison if you will. However, the side effects profile of midazolam still applies regardless of who receives it.

Best wishes and regards for you and your family mate.

I still have potential issues with non-standard concentrations. Sometimes, I run into interesting concentrations mixed by ER nurses and still believe that having a solid, mathematical foundation can be a saver in these situations.

Medicare and other programmes often base reimbursement off of the diagnosis related group (DRG) type system. Basically, an issue or constellation of issues involves a certain set of services or products. Reimbursement for the so called product is based on what DRG the patient falls under. DRG classification is based largely on the ICD classification and a few other factors. Also, certain conditions that are considered hospital acquired and considered largely preventable suc as catheter related infections are typically not reimbursed.

I am not big into humour and off topic discussions, but this really left an impression:

I would not classify Dwayne's sociological musing as Communism however. I had a similar experience to him as well. It was an incredible experience gathering around the table with my mates at meal time and having what I can only describe as a "family dinner." Even better, was the fact that I was the only American, yet was living a common experience with people who were from all parts of the globe. Of course, we all had good reason to get along, mainly self preservation and the fact that we were being paid good wages. Again, I think a certain amount of relativistic context is needed to look beyond our own experiences and biases. However, I must admit my own bias, and it is not consistent with Dwayne's vision as presently presented. I am very independent and often use my living area as my personal think tank. Sometimes, I yell at my self or talk through the many ideas I have rolling around in my head. Clearly, a potential issue when living in close quarters with other people. Even though I am married, we are both fiercely independent and live accordingly. I did contract work overseas and was in the military and my wife is currently doing remote medicine up north. Therefore, we resonate perfectly, a situation that I do not expect to occur with any degree of frequency.

Dwayne, I am actually not being funny with any of my comments.

EMTALA has not changed. Unfortunately, I'm not as optimistic. Even with great follow up and perfect compliance, people with chronic problems can acutely decompensate if you will. We've all seen what a run of the mill Billy Ray Viral infection can do to some diabetics.

Yeah. At the end of the day, we are talking about Dwayne setting up his own living situation and not fundamentally changing society. It is important to make that differentiation.

Cultural relativism applies more to our personal bias when we study or appreciate cultural characteristics that are different from our own. Cultural relativism does not really apply to blending in with other cultures while working as a contractor. You could better define that as participant observation. However, that concept also applies to the scientific study of other cultures. What Dwayne did was likely a form of self preservation. "When in Rome" and all that, if his experiences were similar my own. In all seriousness, I'm am not arguing or telling Dwayne that he needs a certain setup up or should conduct his communal experience in a certain way. I am only attempting to ensure we at least broadly consider the biggest picture possible. Ultimately, Dwayne is legally able to have pretty much any type of situation he chooses, assuming it does not break any laws. It is my hope that I can bring a different and perhaps unique perspective to the picture. However, I also must admit that I have a strongly libertarian social bias. Take that for what you think it's worth.

I'm sure this is a pun, but it looks like I am a bit too dense to make the connection today.

That was not exactly the point I was trying to make. Regarding problems and possible Oxygen contraindications: Consider cyanotic heart defects and paraquat toxicity.

Considering that the contemporary female shaving movement was heavily influenced by marketing campaigns such as the promotion of razors, I have to question why we consider this an integral component of a polite, educated society. I think our goals differ somewhat. My interest is in the continuation and technological advancement of society. Ultimately, we must take to the stars for humanity to survive. This cannot occur unless humanity puts its best foot foreword and embraces creative diversity. If humanity is not able to overcome it's current issues, it will cease to exist. Therefore, my frame of reference is based around human advancement. Self preservation if you will. As I've stated earlier, there is a significant body of evidence regarding human behaviour and society when you look to the fields of anthropology, sociology and psychology. A key component of studying the human condition is known as cultural relativism. We often tend to think our personal notations of norms and mores are correct, but we can learn much when we take a more relative approach to the human condition. As I've stated, you may want to consider taking some anthropology courses if possible. If anything, they may give you a better idea of what you want to do.

Well, I think we need to look at things with more detail. I am going to oversimplify a bit because I'm not sure how well you may understand chemistry, particularly equilibrium reactions and I think I can convey the concept without all the detail in any event. First, many people are under the misguided opinion that CO2 is the primary respiratory stimulus. That's is not exactly the case. Ph changes are actually very important to consider. It just so happens that an increase in CO2 will often decrease Ph and trigger central chemoreceptors. However, this is because the CO2 is transported in the form of HCO3- and H+ ions (for the most part). So, CO2 is converted into an acid and the associated Ph change stimulates breathing. (One of the mechanisms). However, consider a patient in DKA. They are ventilating like a big dog. often, they have a very low CO2, so what is going on? Well, their Ph is low and remember what we just discussed regarding Ph and respiratory stimulation. Where am I going with this? Consider the following. A COPD patient has chronically elevated CO2. What happens with chronically altered respiratory related Ph changes? We develop renal compensation and the body creates more HCO3-. Do, we have a patient with a chronically elevated CO2, but their Ph is relatively normal due to renal compensation. So, in this situation, we would not expect respiratory stimulation because our Ph is relatively normal. Where exactly is this hypoxic drive in what I discussed above? Well, the hypoxic drive theory many not even apply in many patients or it may not play a significant role in the deterioration of COPD patients. It may exist, but the traditional way we look at it is not really all that valid.

I never said that we should ignore standards; however, basing standards on arbitrary, sweeping generalisations is probably not a sound method. My take is to look at the evidence and identify behaviours that are clearly pernicious and carefully develop a road map based on the evidence. As far as "like mindedness," it's a mixed bag IMHO. The very differences and wide diversity of human societies often lead to conflict, while at the same time, lead to great discoveries. However, my initial concern remains. We develop a society that lacks diversity with too much of a focus on "like mindedness," and we develop a living situation that ultimately limits creativity, self expression and the advancement of new ideas. I appreciate the discussion.

The problem with focusing on like mindedness is that we can have a tendency to become too homogenous. Creativity and diversity can lead down significantly different and productive avenues. For example, many of the greatest ideas and advances of human existence came from people who were highly unconventional to say the least. Look at people like Schrodinger, Newton, Socrates, Dirac and Feynman. They all had very different and counter-cultureish lifestyles, yet their ideas changed the course of human civilisation. Heck, even forced suicide, the fall of ancient civilisation and hundreds of years of religious oppression could not wipe away ancient Greek philosophy. Edit: "from"

What is wrong with women not shaving? Body hair is a natural, biological function. The only issue I can appreciate is one that is imposed due to social dogma with no significant biological basis.

Forcing fluid across a membrane may be a mechanism, but it's not an adequate way of looking at what is going on. The fluid issue is largely a consequence of decreased preload from positive pressure and decreased myocardial workload along with a decrease in fluid backup. Of course, this can lead to decreased cardiac output. In addition, you have a degree of pulmonary splinting and possible alveolar recruitment. You also increase your FRC and overall alveolar surface area and can decrease overall work of breathing (see law of LaPlace). In summary, several complex mechanisms occur. I would add that asthma or other forms of COPD are not contraindications for CPAP; however, medical director guidelines can vary significantly. There is evidence that CPAP can be helpful when used on asthma patients. Also, I want to emphasise that using CPAP for pneumonia (non-community acquired) is not contraindicated per se. The data is just limited at this time. Moby may be back here saying "I told you so" in a few years for all we know. Edit: "Not adequate" seems a bit harsh and that is not the tone I wanted to convey. I wanted to emphasise a more complete picture.

I'm not so sure. The United States is becoming increasingly bilingual. If I had children, they would learn both Spanish and English. Like it or not, Spanish is becoming an integral component of American life.

The hypoxic drive of death is a scarecrow that for some reason continues to haunt this site among others. However, there has been much research into the problems associated with prolongued exposure to higher than normal FiO2's. I suggest you guys take a look at the 2010 AHA guidelines as a starting point. At this point, the general suggestion is to titrate to a SPO2 of around 94%. A summary of the 2010 guidelines: http://guidelines.ecc.org/pdf/90-1043_ECC_2010_Guidelines_Highlights_noRecycle.pdf However, I also suggest you guys look at other types of literature as well.

I'm not exactly sure what we are talking about regarding the term "high flow." Richard, I'm not clear on why CPAP for sleep apnoea would be considered off lable. I would not call sleep apnoea an acute issue however. Also, we generally divide sleep apnoea into two broad classes; obstructive and central. I would agree that treating central with CPAP could be off lable. I don't really want to go that far off from the OP's main point because it is a good point to consider. Even though there is a lack of evidence except with community acquired pneumonia, with more literature, the current paradigm very well may change.

Dwaye, ever consider taking an anthropology or sociology class? It's interesting, but independence is often an integral social component of society in the United States. Babies have their own cribs, kids often have their own rooms, children are often assessed on individual achievement examinations and so on. The somewhat non-communal behaviour you seem to point at is not unexpected. However, you see that change somewhat in areas where other cultures are heavily integrated into the overall social structure.

Moby, if you mean Lasix for pneumonia, yes it's not helpful and possibly harmful. However, Lasix in general is not useless. If you have bronchospasm, treat it. However, patients with pneumonia don't necessarily have bronchospasm. I do not support arbitrary, needless use of treatment modalities. If you can make a good case for spasm, fine. This is quite possible with physical exam backed up by waveform capnography. I gather you are talking about treating appropriately and not arbitrarily. Crap, I am not sure I follow your logic? People with pneumonia may need fluids for a variety of reasons. The goal of CPAP is not to dry out secretions; however, I suppose there is a potential concern of that occurring in the field, maybe. In the hospital, we often heat and humidify patients receiving NIV. In fact, there are reports that NIV may help clear retained secretions.

Another consideration is metabolic syndrome. However, I would expect some degree of fatty liver changes, so concomitant issues may also be present with this person.