chbare

Dwayne, you've really defined a profound concept. I would add that I look at things like this; our sun is around half way through it's main sequence. In all the billions of years up to this point, life in our sun's system has only developed to the point of having a few theories that cannot be tested, but attempt to define how our existence began. The best tools (that have physical evidence to back them up) we have available such as relativity break down into infinities when considering the possible beginning of our universe. By no means are our tools lacking in scientific insight and infact they are the best thing that billions of years of evolution can bring to the table to explain existence if you will. Yet, they break down, are hotly debated and continue to become more and more abstract. So, we really do not have a clue about the mechanisms that caused existence IMHO. I'm not even sure existence is a good word to define what I'm thinking about. With that, what I find it difficult to understand is how people on both sides of the God argument can be so hateful when humanity does not really know Jack Schyte IMHO. Personal beliefs are fine but what said governor did was not acceptable IMHO. As far as everybody else, I wish people would quit trying to one up each other on an argument that is currently inane IMHO. One more IMHO for good measure. Take care, chbare.

Hey guys, the physiology of diaphoresis is exceedingly complicated. Sweat glands are heavily innervated by cholinergic receptors but diaphoresis is often the result of a sympathetic response. Clearly, the basic intuition regarding autonomic nervous physiology breaks down. You need not have tachycardia to have diaphoresis; however, being that a sympathetic response is often associated with diaphoresis, it's no surprise that tachycardia is often associated with said response. Take care, chbare.

Thanks for sharing bro. As I stated, I was not totally confident and would have been hesitant to give any medication. I would have still cardioverted, but I really appreciate you sharing this with us. Definitely a good case. Take care, chbare.

Is it ventricular tachycardia, is there an underlying atrial flutter, what will happen when I start altering ion channels with medications? This is basically what I'm thinking. The safest consideration in my mind is to consider csrdioversion. Take care, chbare.

Late in the game; however, I am not particularly confident in a definitive field diagnosis of the rhythm in question. I would be very cautious about pushing meds. Honestly, I would cardiovert at this point. Take care, chbare.

http://www.bcctpc.org/ It is highly recommended that you have three years of experience prior to looking at either the credentials of ground or flight. The CCEMTP course may not cover all the testable information on these exams. Good luck and take care, chbare.

However, I dare say this situation was a little unique? Take care, chbare.

We don't really know what occurred and the reports seem to indicate this guy made some good medical decisions and was actually quite helpful on scene. She was also delivered to UMC very quickly and on her way to the theatre in about 30 minutes. Dr. Rhee has credited her pre-hospital course as being helpful and ultimately resulting in her rapid delivery to UMC. In spite of what some may think, assume or say, all indications are pointing to good delivery of care in spite of letting the guy ride in the back. A judgment call was made in the middle of what had to be a terrible situation and it may have paid off on this case. Perhaps, it could have been disastrous, but I see no real benefit in Monday morning quarterbacking things at this point. Take care, chbare. "In."

Huh? He held her hand, not exactly in the way... Take care, chbare.

The 5 litre and 4 litre values were somewhat arbitrary and simply numbers that I used to quantify the concept of 0.8 being normal. The reality is that in an "ideal" situation, you would have near perfect matching. The math involved is fairly easy: Blood: To calculate the content of oxygen contained in blood, use the following equation: CaO2 = (1.34 * Hb * SaO2) + (PaO2 * 0.003) The 1.34 is a constant that assumes every gram of Hb can contain 1.34 ml of oxygen. The 0.003 is a constant as well. The answer will be in Vol% or ml per 100 ml of blood. In a perfectly ideal situation, you will have 20 ml per 100 ml or 200 ml per 1,000 ml. Air: Under ideal conditions with dry air, you will have about 210 ml of oxygen per every litre of air inhaled. So, in an ideal situation, you can see that VQ matching should be nearly 100%. However, in reality many factors such as gravitational effects, deadspace, and physiological shunting ensure you will not have a perfect 1:1 VQ ratio. The 0.8 is an average value that takes many of these factors into consideration. I hope that helps. Take care, chbare.

The VQ ratio is basically the amount of ventilation in and out of the lungs compared to the amount of circulation in and out of the lungs. A normal ventilation to perfusion ratio is about 4:5 or 0.8. Think about a person who has a minute ventilation of 4 litres per minute and perfusion through the lungs of about 5 litres per minute. In other words, ventilation through the lungs should approximate perfusion through the lungs. A ratio higher than 0.8 means there is more ventilation than perfusion and lower than 0.8 means that there is poor ventilation. Take care, chbare.

Unfortunately, due to potential legal implications I do not feel like I could give medical advice over a public forum. I would suggest you discuss this with your medical provider. Sorry, I am not all that keen on giving medical advice on this forum regarding such a complicated situation. Good luck and take care. chbare.

However, you have not looked at the other side of the issue. You state that mannitol must be given, yet you do not provide a compelling case IMHO. The evidence you presented actually presents a compelling case against pre-hospital mannitol administration in many cases. Quoted from the article: "Because mannitol causes significant diuresis, electrolytes and serum osmolality must be monitored carefully during its use. In addition, careful attention must be given to providing sufficient hydration to maintain euvolemia. The limit for mannitol is 4 g/kg/d. At daily doses higher than this, mannitol can cause renal toxicity. Mannitol should not be given if the patient's serum sodium level is greater than 145 or serum osmolality is greater than 315 mOsm." Are you able to monitor labs in field? Are you able to assess or calculate serum osmolality in the field? Could you manage an electrolyte derangement if one occurred? "Boluses of mannitol can generate a dramatic diuresis, resulting in rapid intravascular depletion and potential kidney damage. Mannitol can cause as much as 1500 cc of fluid to diurese in the space of 2 hours, as intravascular fluid depletion occurs, hematocrit can rise, blood viscosity can increase, and cloning is enhanced. This makes the area of brain irritation much more amenable to stroke." Are you able to place urinary catheters and adequately monitor input and output? We must be able to appreciate the benefits and pitfalls of implementing modalities. Physicians as well must decide what risks and benefits are associated with a specific modality and ultimately decide if a modality can be implemented in a way where benefits outweigh the risks. Can you provide good, peer reviewed evidence that implementing a mannitol protocol in a system similar to your system leads to clear benefits in patient morbidity and mortality? If so, you should use this evidence, but also acknowledge the risks and find evidence or methods that will minimalise these risks. Unfortunately, a link to emedicine and a paragraph stating that mannitol must be given is less than compelling. It's great when casually discussing topics on this site, but inadequate when you are approaching medical direction or a committee about changing policy, procedure and/or protocol. I have actually been involved in this process and failed miserably. At one point I really wanted my company to have a ketamine protocol. However, during my research, I could not find any compelling evidence that using ketamine was better than our current protocols. I wanted to use it, had good anecdotal experiences with it, but the reality was that the evidence was less than compelling to support company wide policy and protocol changes. Take care, chbare.

I have no problem with scrubs; however, a uniform is also a function of the environment. Unfortunately, the operational environment of EMS is frequently different than that of the hospital. I think a uniform should reflect this axiom. I wore a 5.11 uniform as my standard kit while overseas. This included a navy polo, khaki 5.11 pants and a nice pair of desert tan boots. I kept the pants and polo wrinkle free and found the overall uniform to be quite functional, professional looking and durable. This is an example of a good looking and practical uniform IMHO. Take care, chbare.

One thing we need to realise early on is that the best we can hope for is an indeterministic assessment of the physical world. In that I mean, our most complicated tools are really only based on the toss of a coin or die. Therefore, it can be exceedingly difficult making sense of our world in meaningful and consistent ways. So, we have to understand the limitations of EBM and the techniques we use to make sense of evidence. With that said, it is not difficult to appreciate the variance in opinions and the ways in which people interpret information. I will give you a very basic example: Let's say I have a data set of 5 people. Let's say we are trying a new EMS treatment on trauma patients? The data set will be patient's who responded with an increase in their mean arterial pressure above some threshold. We can have say three thresholds. One is minimal response, two is moderate and three is good response. Patients who did not make threshold 1 will be identified as threshold 0. patient one: threshold 3, patient 2: threshold 3, patient 3: threshold 1, patient 4: threshold 1, patient 5: threshold 0 This gives me, 3,3,1,1,0 Let's say I want to get an average of these findings. Well, I can choose three different techniques: 1) Mean: Add em up and divide: 8/5 = 1.6 2) Median: Order and choose the middle: 0,1,1,3,3 ---> = 1 3) Mode: Most common number, I can go with either one or three So, in our simple problem above how do we interpret the data? The mean and median suggest it may not be all that effective (of course, I never defined effective), but the mode could go either way. What do we do? Look at more patients, get a confidence interval and Z score, look at the standard deviation, do a new study and define our responses differently and so on. What if we keep drawing blanks? Clearly, something is going on with our data, but not everybody will agree on what that something is or how it should be interpreted or implemented. This is where the importance of consensus and multiple studies that are peer reviewed comes into play I think. Many guidelines such as the surviving sepsis guidelines are based on consensus where people basically look at data and then play a game of give and take compromise on recommendations that they can at least live with. So, I absolutely agree with EBM and thinks it's the best we currently have available, but we must recognise that it can be difficult to make any definitive conclusions in many cases. Take care, chbare.

I assume you are talking about the AK and it's various amalgmations? There were clear benefits to carrying these types of weapons in Afghanistan; however, I am not sure about carrying such a system as a tactical medic stateside? My issues very well may be due to a lack of trigger time on said weapon systems. My issues: 1) The mechanism and process for performing tactical and emergency magazine changes is very non-intuitive, cumbersome and requires a fair amount of fine motor coordination. Clearly, I think this is detrimental when you are placed into a situation where the acute stress encountered can degrade one's ability to perform tasks requiring fine motor coordination. 2) Not too many agencies use such a weapon system as part of their standard kit as far as I am aware of. Clearly, you would be using a different system than the people in your squad or unit. It is my personal bias that team members should typically carry a similar kit and utiise weapons that have the same mechanical characteristics and use the same type of ammunition. Obviously, highly specialised roles such as a sniper element or using a shotgun to breach will be an exception. I am not sure this applies to a medic carrying an AK variant system however. 3) Some of the AK variant systems may require modification to accept items such as aimpoints, lighting systems and so on. I know many mods exist and are fairly easy to use and even some AK variant system are being produced stock with picatinny rails and so on; however, I still think from a logistical and familiarity standpoint, going with a "standard" system may be a better idea. My thoughts for what they are worth. Take care, chbare.

At one time people used this modality because they thought it would decrease after load and myocardial work load in patients experiencing decompensated CHF and cardiogenic pulmonary oedema. Take care, chbare.

It is somewhat of a tongue in cheek statement. Basically, nursing has gone to great lengths to place emphasis on the fact that nursing is a unique profession with a unique core of knowledge that only nurses possess and utilise. Many theorists are quick to point out that nurses do not "practice" medicine as nursing is distinct and separate from medicine. Take care, chbare.

Again I ask, how would you justify removing a functional backup device if your swaparoo with a bougie trick failed? I am not saying you are necessarily wrong; however, if your plan to exchange fails, you could be potentially left without any airway. So, I see this as a procedure with questionable benefit and potential disaster written all over it. I am not so sure the benefit would outweigh the risk in this case. Clearly, I am not convinced with any of the "definitive" airway and "aspiration" risk comments at this point in time. Take care, chbare.

To go off on a tangent, I would say there is a big difference between the physician assistant and many nurse practitioners. There exists a large movement among nurse practitioners advocating complete independence of practice. In essence, you have a provider working without any physician input or collaboration and basically taking on the role of the physician. Arizona, for example does not require any agreement of collaboration between a NP or a physician. Basically, I can open a clinic and set up shop like any other physician. Clearly, this is much different than simple skills or knowledge overlap of a nurse and a paramedic. Another movement that has a significant amount of momentum is the concept of a "Doctor nurse practitioner." Basically, NP's go back to school for a while, do a few hundred hours of clinicals and come out with a clinical doctoral degree in nursing. A massive push is in effect and presumably, by around 2015 all new NP's must have this "doctor" degree. While I am not against education, this degree is catalysing some people to push for sweeping doctor nurse privileges. Obviously, I think this differs from the situation involving a PA where the PA has a physician relationship and is ultimately accountable to a board of medicine. My opinion for what it's worth, and not a particularly popular opinion among some nursing circles. Take care, chbare.

Nurses do not practice medicine. Take care, chbare.

Yeeahhh...the Roman Empire spanned something like 16 or 17 centuries and had periods of alternating good times and bad times so to speak. Clearly, more than giving in to sinful wishes was going on at any given period in time. It would be very myopic and uninformed to make such a sweeping generalisation when the history of Rome was and is still highly complicated. Why would homosexuals only serve in support roles? Again, is there a solid base of evidence that you can use to back up such claims. Otherwise, we are making arbitrary assignments. Gays can make the food, swingers can run logistics, bisexuals can do intel and heterosexuals can do the killing? Take care, chbare.

You don't know what you don't know bro. When you are running down your list of differentials for a raised anion gap acidosis, the causes directly relate to chemistry. How about dealing with certain types of overdoses? What does changing Ph have to do with protein conformation and ultimately protein binding? What will electrolyte abnormalities do to membrane potentials? How are anions and cations different from their parent atoms in nature? How about letting a trauma patient become hypothermic? What will chemistry dictate there? Will our interventions based on the chemistry lead to improved survival? Another consideration is people may take you seriously and trust your judgment, ultimately that can lead to improved outcomes. When a physician asks you about energy production and all you can say is "well it has something to do with the Krebs cycle," they are going to be less inclined to trust you. It happens, several of the physicians in my area are involved with education. The pulmonary Docs love to grill students during rounds. It's also really embarrassing when somebody asks you to explain what's in a bag of NS (a med you administer all the time) and you cannot explain what the 154 miliequivalents of sodium and chloride means, even though it's on the front of the bag. About microbiology; we are transporting more patients with infections and related complications. Perhaps you can help make a connection and ensure a patient receives proper antimicrobial coverage? Or is this something unimportant to the likes of EMS. Knowing what an acid fast positive sputum culture is may spare you some serious problems. Had a crew take a patient with a AFB + sputum culture from an ER that may or may not be local to me. Unfortunately, they did not know what AFB+ potentially implied and the hospital wanted the patient out. Oops... EDIT: Regarding computers; a paramedic friend just took a job doing trauma epidemiology tracking and research. Tell me she doesn't use computers? You need to look beyond your little area of the world and recognise the proliferation of paramedics into many others areas of healthcare. Additionally, I am not saying we need to have a year of Gen-chem, a year of O-chem, a semester of P-chem and some analytical chem thrown in for fun. I would like to see a semester of chem with a lab required however. I can go on and on; however,as I stated, sometimes you simply don't know what you don't know. Take care, chbare.

Caveat: I would say I identify with some sort of Christian faith. If you believe my "faith" somehow degrades my view on the topic at hand, feel free to disagree with what I have to say. All this talk of God, "normality" and homosexuality is quite interesting and great for philosophers; however, I am not sure what phrases I use to best describe my belief in a divine mechanism or lifestyle is all the relevant to the crux of this thread? My question continues to be, does good evidence that suggests homosexuals in the military will harmfully impact the military exist? If so, great, let us debate said evidence. Thus far, I have found nothing compelling and have no valid reason to oppose the destruction of "Don't ask don't tell." Take care, chbare.

You cannot appreciate organic chemistry without a good foundation in general chemistry. Much of organic chemistry revolves around electron interactions (well, most of chemistry). However, in organic chemistry, you deal with carbon based compounds, molecules and substances. Carbon is truly unique. You will learn a little about the quantum mechanics of chemistry in general chemistry and will probably cover Lewis and VSEPR theory. However, these fail in certain cases and Carbon happens to be one of these cases. Basically, we know carbon can form up to four single covalent bonds; however, traditional theory would not predict this. If you examine the electron configuration of Carbon, you would find it's valence electrons exist in P orbitals. Each P orbital has one electron and conventional wisdom would assume three bonds are possible with Carbon. Unfortunately, we know up to four are possible, and they have the same energy. This is were your traditional chemical concepts begin to break down. What we actually have to do is go back to gen chem when we talked about the basics of treating the wave aspect of an electron with something known as a wavefunction. When we do this, we actually are able to combine the wave function of the P orbitals with the wavefunction of the S orbital that is at a lower energy than the P orbitals. When properly treated this way, we get something known as constructive interference and we can hybridise the singe S orbital and three P orbitals into four SP3 orbitals. When this occurs, we can account for four bonds at the same energy levels. To make matters even more complicated, Carbon can have SP2 hybrid, SP hybrid and P orbital bonding. I believe Carbon may be a unique atom in this regard. I may be corrected as my O-chem is not all that strong. The take home point of all that is, you need to have a very strong foundation in general chemistry before you try to tackle something like O-chem. As far as explaining the importance of microbiology and chemistry outside of the lab? I am afraid the importance of these subjects is pretty much an axiom. Numerous implications exist here form understanding what giving an amp of bicarb will do to carbon dioxide levels to understanding wat a + acid fast bacilli screen means. Also, you cannot truly understand the significance of any of the medications you give without chemistry. Even something as fundamental of ATP production through oxidative pathways cannot be appreciated without an understanding of chemistry. Take care, chbare.