chbare

I thought I would present an interesting case based on one of my Afghanistan experiences. I'll see what you guys think. You are pulling clinic duty out in the middle of nowhere when a 36 year old male presents to the clinic with complaints of sudden onset chest pain. Take care, chbare.

The vasopressin for arrest change is due to literature reporting that in certain cases of arrest, the survival to admission rates were higher in the vasopressin groups. I think survival to admit rates were much higher in asystole groups. Yes and no. Clearly, the risks associated with SB insertion are pretty significant under the best of circumstances. Hence, the reason SB treatment as a primary modality has fallen out of favour in recent years. Take care, chbare.

The emphasis is on controlling the bleeding with vasopressin infusions, not treating hypovolemic shock. We also must remember the vessels involved are veins, and arterioles eventually branch out into capillaries, and capillaries eventually lead to veins. Therefore, constricting arterioles up stream so to speak can assist with controlling the venous bleeding downstream. Take care, chbare.

I think nonselective beta blockers are recommended, Inderal happens to be the "parent" of this class of beta blockers. With that, I am not sure any pharmacological therapy really reduces mortality. I think there may be limited evidence that the newer vasopressin analogues may impact mortality. SB tubes have rather fallen out of favour in recent years. The last one I saw was secured to a football helmet. Honestly, there are many risks to placing a SB and not much in the way of benefit IMHO. I day say endoscopic techniques are the standard and have pretty much replaced SB tubes. Especially since somebody well educated in SB tubes should be the one placing the tube. If this is the case, the patient is most likely where they need to be. While I may galvanise people into hating me, I would absolutely recommend nasogastric intubation. I do find it ironic that in the same discussion we are talking about the harm a combitube can cause, yet discussing SB tube use as a therapy. Anybody who has seen a SB tube should understand the irony of that dichotomy. Take care, chbare.

As touched on by Flight, the goal with utilising vasopressin is hemorrhage control by constriction of arterioles. Vasopressin is actually very effective at initial hemorrhage control, but re-bleeding can occur quite frequently. Take care, chbare.

Not sure I follow, why are you so worried about giving fluids to this patient? You can always be judicious with your delivery method; however, nothing about this scenario screams of fluid contraindications. Take care, chbare.

The golden hour...really? Take care, chbare.

There is no reason to loose the plot over this stuff or assume "bashing." Take care, chbare.

ERDoc, a serious question and no sarcasm intended; using much imagination and filling in the blank details, would you fault a paramedic for not wanting to take this patient? Take care, chbare.

Ok, thanks. I did not see the offending post and assumed my post was interpreted as being overly negative. Take care, chbare.

Perhaps a fair question to ask is, with the avaliable information would you as the paramedic have transported this patient? Personally, I am not going to transport a 25 weeker having contractions every four minutes regardless of station, dilation, or effacement. Even with the ability to intubate, I have no isolette, no surfactant, no ventilator able to manage such a small patient and no other high risk neonatal resources. JPINFV, I understand the damned if you do or do not argument; however, I personally would not have transported this patient with the information we have available. Take care, chbare.

It's going to be a long while before JP is independently making those decisions. You always contribute so much and I appreciate your involvement and discussions, but JP will have many years and a whole lot of experience before making these decisions, so it's kind of a cheap shot throwing out that question. Take care, chbare.

I do not think I'm being negative or unreasonable. Many of us have beliefs that are more or less faith based. However, if we are discussing empathy, why not debate the various types of evidence that support one view or another. I suspect more conventional concepts such as inflection, body language, and multiple other cues and the ability to be aware and interpret these said cues plays an important role in being empathetic. Take care, chbare.

While I think some people are good at being empathetic, I am not aware of any evidence that says this ability is preturnatural. Take care, chbare.

Come on guys, let's keep this civil? Take care, chbare.

Glad to see you are still around Mr. Bohr. Take care, chbare.

Just to clarify a few points: 1) Pyruvate is a product of glycolysis along with a net of 2 ATP via substrate level phosphorylation. In addition, two NADH are produced per glucose molecule. However, the pyruvate is turned into acetyl-CoA after entering the mitochondria. Lactate is produced in the TCA cycle. 2) The Krebs Cycle (TCA) is not the major ATP producing pathway. I believe only about two ATP are produced via substrate level phosphorylation in the TCA cycle. The major site of energy production is the ETC. Hydrogen ions and electrons help run ATP production in two ways. 1) The electrons give up energy as they cascade through the cycle. 2) Hydronium ions are utilised to make a gradient and by use of proton motive force (PMF) powers ADP to ATP conversion through a protein known as ATP synthase. The oxygen "scavenges" the hydronium ions and electrons at the cytochrome c oxidase protein complex. 3) Several things actually occur beyond cell death by acidosis. We have failure of multiple mechanisms including ion channels. Then, as cells die, inflammatory mediators are released opening a systemic bag of worms. This is part of why people with say a femur fracture can develop ARDS and MODS. Clearly, hypoperfusion related to hypovolemia can be another part of the puzzle. However, it is not uncommon for somebody to sustain a hypoxic insult or an episode of hypovolemia and end up developing MODS and so on. I am sure the Docs and JPINFV can go deeper, but I just wanted to clear a few thing up. Take care, chbare.

Glycolysis does not require oxygen; however, ATP production is rather modest via glycolysis. As stated, the ETC requires the electronegativity of oxygen to act as an electron receptor. This is an aerobic process and by proxy the TCA cycle is as reduced NAD & FAD needs to dump off protons and electrons. Why not take a microbiology course or study up on what happens to pyruvic acid in an anerobic environment. In addition, you should appreciate what happens when ion channels are no longer to move ions and various other cellular activities that require ATP. Take care, chbare.

Don't care. Male or female, may the most qualified provider win. Had a female provider present when I got fixed, cannot say I had any issues. Nor do I care if people do not want me taking care of them on the account of my genetic disorder. Nothing personal IMHO. Take care, chbare.

However, the discussion is not necessarily revolving around your specific system or experience, therefore your views regarding nurses may not even apply to the situation at hand. While we do not know what system we are dealing with definitively, would you continue to have the same opinion assuming we are in fact dealing with the Dutch system? Take care, chbare.

Your post was a hunch, so I do not have anything definitive to go on at this point. If your hunch is indeed correct, it would seem the current system may serve as somewhat of a model; however, the OP has yet to make additional comments. Take care, chbare.

I think we are getting a little ahead of ourselves. What country are we talking about? What system, what services are provided by this system, what is the education of "EMT's" and nurses in this country, how does the current system work, and what is the rationale for new changes? Its inane IMHO to discuss a concept without knowing any of the details. Take care, chbare.

In one sense, there are cases when we do administer a substance that works in a similar way to detergent. The most common scenario is administering surfactant in the setting of surfactant deficiency syndrome. I am not sure I understand the FiO2 question. Clearly, it is not possible to deliver more than an FiO2 of 1.0; however, my point being there is a profound difference between flow and FiO2. For example, I can place somebody on mechanical ventilation with a flow of 60 LPM yet only have an FiO2 of 0.21. Likewise, I can breath a gas mix under several atmospheres of pressure that utilises a sub-atmospheric FiO2, yet have a partial pressure of oxygen can be higher than what is encountered at sea level. Therefore, the concepts of FiO2, partial pressure, and flow are quite different. Take care, chbare.

Actually, COPD patients often do require high flow modalities. Remember, high FiO2 and high flow are profoundly different concepts. Additionally, a NRM at 15 LPM is NOT a high flow modality. Simply stated, a high flow modality must meet or exceed the patient's flow requirements. A simplified way to view it is the following; Say I have a Vt of 500 and I am having some respiratory distress and am breathing at say 34 times a minute. That gives me a minute ventilation of 17 litres. Will a NRM at 15 LPM meet my inspiratory flow requirement? That is not even throwing in other concepts that can alter the flow requirement. In addition, a loop diuretic is not a cure all for every patient with CHF. We need to be very careful about giving loop diuretics in the pre-hospital environment. In addition, other modalities should be considered. Take care, chbare. EDIT: added an '.

I just want to emphasize a point Vent made earlier. Not all dyspnea patients need or will be helped by a bronchodilator. Specifically, not all pneumonia patients with dyspnea need bronchodilators. Pneumonia is fairly specific to the alveoli, if your patient has an alveoli problem without bronchospasm, dilators are not all that helpful. Remember, we do not have beta adrenergic receptors in our alveoli, contrary to what many people believe. Rather, the decision to use a dilator should be based on good evidence pointing to bronchospasm. Unfortunately, albuterol is not the scrubbing bubbles all purpose lung cleaner and general purpose respiratory cure all that people often make it out to be. Take care, chbare. Vent was stating Duoneb is a brand name for a medication produced by a specific company, Dey Laboratories. In fact, Duoneb does come in a single dose container. Therefore mixing your equivalent of a Duoneb is not technically Duoneb as this is in fact a brand name. Take care, chbare.