chbare

Global warming as a theory is ~ to gravity? Take care, chbare.

It's likely he's had this for a while. What did you end up doing? Take care, chbare.

This wonderful work of art should help: Take care, chbare.

Apologies for the typos, meaty fingers and an iPhone do not always mix. Take care, chbare.

Remember your A&P for this one. You have three primary fascicles. One on the right and two on the left. The two left fascicles are the left anterior and left posterior. So, with a RBBB, you have a block of the right fascicle, but the two left fascicles are intact. A RBBB with a bifascicular block means you have a RBBB and one of the two fascicles on the left are compromised. Clearly, this may be a problem as you only have one pathway for conduction to travel. A trifascicular block would be a block of all three fascicles and a patient who may look at getting a pacemaker. You could also consider a LBBB bifascicular as you have both the left anterior and left posterior fascicle blocked. I cannot comment on your patient. I would not go so far as to say a bifascicular block alone requires q helicopter. This guy may have been living with a bifascicular block for years. It is something to monitor however. Clearly, these blocks are a concern when you actually see them occur while doing serial ECG's on a patient having an MI. You should familiarise yourself with identifying these anomalies as the machine can lie on occasion. This requires being able to identify axis deviation and bundle branch blocks. If yup are able to do this, I have an easy algorithm for putting it all together. Likewise, I use the ResQShop software on my iPhone that actually guides you throughout the process step by step. Take care, chbare.

You are correct and if EMS decides to take any initiative, this can potentially have profound implications. I see this as a potential step toward firmly establishing the paramedic as a true allied professional much like a physiotherapist or respiratory therapist. This same move was performed some years back when respiratory therapy removed the CRTT level and placed more professional and educational emphasis on the entry level providers. Currently, the CRT and RRT exist and the push is significant toward RRT licensure. Clearly, this and other moves has allowed respiratory therapy to expand the RCP role. The paramedic role could very well undergo a similar metamorphosis, assuming EMS is ready to take steps foreword. I am not sure that volley and fire based control mechanisms are all that keen on having a more independent and established paramedic that is truly considered an allied professional. Clearly, I have my doubts and think there is a good chance the name change will simply mean a slightly different way of spelling the same old mediocrity. Take care, chbare.

Meatspin.com is or was an adult site that opened to a video and the tune of " you spin me round like a record." I would not recommend looking at the site (if it is still in existence) if you have any prudish tendencies. It's a case of that what has been seen cannot be unseen. Take care, chbare.

Payback. I worked with a nurse some years back who was always hassled by our A&P (airframe and power plant), sort of life an aeroplane or helicopter mechanic. Je would ask her to find non existent things such as "rotor wash" and "blade lubricant." Over the months, she managed to find out his laptop password, I assume by watching him type it. Then, one night after leaving his laptop at the base, she hacked into in and changed his Internet homepage to meatspin. You can imagine the surprise he had in the morning... Take care, chbare.

Thanks, I am glad you guys enjoyed this one. Take care, chbare.

First, I want to emphasise that this is not a critical situation in light of the patients injuries. This is more of an exercise in mental masturbation with all the trauma stuff thrown in as a distraction. Also, this is somewhat of a novel concept; however, I know of at least one case in the literature. There exists a physical concept known as the Coanda effect. It essentially states that in some situations a fluid will have a tendency to attach to a surface and follow the said surface. Fluid in a physical sense can be a gas or a liquid as both have fluid like characteristics when in motion. An easy do at home example of this effect involves a candle and a can of soup. Light the candle and put it in front of the can of soup. Blow a stream of air on the other side of the can. Conventional wisdom says the can should stop the flow of air. However, the air attaches to the surface of the can and contours around it to blow the candle out. In this case, the deviation placed the ETT near or on the right tracheal wall. The flow of air attached to the wall and followed it into the right lung. Then, as the lung filled, the air essentially spilled over into the left lung so to speak. This is what led to the asymmetrical expansion I have a rather bad drawing attached to better view the effect. An art major I am not: In the actual case stude, the provider rotated the ETT by about 90 degrees and was able to resolve the asymmetrical movement problem. I hope you guys enjoyed this one as it was a little different, but still thought provoking hopefully. Take care, chbare.

Lets say there is no blockage, just a deviated trachea. Could this along with ET placement alone cause these findings? If so, is there a physical principle that can explain these findings? Take care, chbare.

If the left bronchus was blocked due to the haematoma, then the left side would not rise at all, no? Or, is there a way to explain what you are seeing? Take care, chbare.

No SC air noted, no indications of a pneumo, no indications of a hemo save the vital signs. Needle decompression does not change the situation. Can these findings be explained by the tracheal deviation? Take care, chbare.

Gastric intubation and decompression is performed. The patient continues to exhibit the asymmetrical chest wall movement. Take care, chbare.

Pulling the tube back a bit dose not change anything. Upon closer examination, you notice a left sided neck hematoma and slight right sided tracheae deviation. The chest wall is intact except for several abrasions, lung sounds are clear, bagging the patient is not difficult. The remainder of your exam is unremarkable except the problems that have already been identified. Take care, chbare. Yes, it does appear to be cerebral protective and the fact that MAP and CPP is typically not altered is another benefit. Take care, chbare.

You are able to successfully place a 7.5 to what appears to be the proper depth. You note chest rise and fall, lung sounds and have a good waveform and end tidal CO2. However, upon closer inspection, the chest rise is initially non symmetrical. You nothce that the right side of the chest begins to rise first, then after a slight delay, the left side begins to rise. Take care, chbare. It's a judgement call. I would most likely go with etomidate and sux; however, you could justify just going with sux due to a crash airway, but anecdotally (n=1), I feel that giving etomidate is quick and would not cause any harm to this patient. While many people in the United States still cling to the ketamine/head injury mantra, I wanted to simply point out the evidence for such beliefs is rather limited. Take care, chbare. Nasal is a consideration. I chose to go oral for the sake of the scenario, but considering nasal intubation, assuming you can keep him well saturated is a consideration. Take care, chbare.

So, doing okay with the NPA's and bag mask. How are we going to roll? We can: A) Continue as a crash airway and simply give sux and tube. Do an RSI. C) Continue doing what we are currently doing. You are looking at a 30 min transport time regardless of your platform. You can call for a flight, but yup would end up being the flight crew. Either way, you will have to deal with the patient for the next half an hour. Additionally, what is the current stance on ketamine and head injuries, assuming we have head injury on our list of differentials for this guy? Take care, chbare.

You are able to place an NPA in each nare and bag the patient with symmetrical chest rise and fall. The cyanosis resolves and bleeding is controlled with direct pressure. The patient remains unresponsive. Vitals: P-118 weak and thready at the radial, RR- was 6-24 and irregular, you have taken over and currently have an apneic patient, BP -92/50, SPO2- 100%, temp-35 Celsius. BGL is within normal range. Take care, chbare. Would you go straight to a surgical? It will take time to prep and we currently have all the criteria for a crash airway. Would you want to consider bag mask ventilation while prepping the patient? Is NPA placement absolutely contraindicated with our current findings? Our immediate goal may not be a "definitive" airway device but rather oxygenation and ventilation. Take care, chbare.

Your partner voices concern over the shallow and irregular respirations along with the continued cyanosis that appears to be even more pronounced at this time. The continued bleeding is of some concern to him as well. Take care, chbare.

You can be a responding HEMS team if you want. The team member or platform selection will not change the scenario. Take care, chbare.

No helmet, abrasions all over the body, 6 cm scalp laceration over right temporal area bleeding profusely and bilateral femoral deformities are all that you see. The patient has truisms and you cannot insert an oral airway. He also looks rather smurf like. Take care, Chbare.

You find him prone out in the dirt about 30 feet from the guard rail with obvious bilateral mid femur deformities. He is not moving and does not respond as you approach. Looks like he went head on into the guard rail and took an up and over off the bike, finishing off this feat of acrobatic skill with a face plant. You notice rapid, shallow and irregular breathing as you approach. The police validate your suspicion with a story that pretty much matches. Tried to stop the dude, he took off, eventually went into a guard rail dodging traffic while attempting to evade the police. Take care, chbare.

Scene is controlled, looks like a motor cycle went head on into a guard rail. Take care, chbare.

Any level you want. 30 Celsius. Just you and your partner. Reported to be a single patient. Take care, chbare.

You are called to the scene of a motorcycle accident... Take care, chbare.