chbare

Even more sad is the fact that we utilised vacuum mattresses and scoop stretchers in Afghanistan, but not longboards. Take care, chbare.

Dude, if the Brits are saying it's an acquired taste, that's a clue to avoid it at all costs. Take care, chbare.

I am not all the certain bombing every patient (if antimicrobial therapy may be indicated) with a third generation cephalosporin is necessarily best practice. Still, ceftriaxone does have a rather broad range of activity. I would want to see some data, especially when used in the setting of Fournier's gangrene. The best therapy is still going to be aggressive surgical intervention. Obviously, antimicrobial coverage will pay a role, I am just not that sure it would change outcomes when utilised in this type of patient as a pre-hospital intervention. Take care, chbare.

I take it you work in the hospital to know about the APACE II scoring system? Thanks for the scenarios. Take care, chbare.

A couple of points: 1) A culture and sensitivity will take more than a day to complete and the gram stain will not help as Fournier's gangrene is polymicrobial. 2) Fournier's gangrene is a form of necrotizing fascitis and should be considered a true emergency requiring rapid transport. 3) Many providers like to have blood cultures drawn prior to antimicrobal therapy. 4) Empiric antimicrobal therapy will be given; however, agents such as Unasyn, Zosyn and others are good considerations. Assuming we have identified the right condition? Take care, chbare.

Yeah, one of the worst cases of my career to date involved a morbidly obese patient with multiple additional co-morbidities who fell and could not get up. He was found down after several days and had developed extensive cellulitis with large, purulent areas of necrosis and drainage. In fact, it was so bad, we initially treated it like a hazmat incident and did an initial cleaning kitted up in our decon room. This particular case was even more disturbing initially than most of what I experienced in Afghanistan. In addition, the patient did a downward spiral on us while we were waiting for Medevac. With luck, the team had a PC 12 and could fly the guy. Unfortunately, the patient did not end up doing well. As Spenac stated, once you go down the road of multiple organ dysfunction and failure, the prognosis is not typically great. Even worse, you run into all the physiological and pharmacological problems with multiple organ failure. Take care, chbare.

With the history, we need to put Fournier's gangrene on or list of differentials. Clearly we also have additional problems such as WPW. If treating the WPW is needed, it will most likely consist of cardioversion as many medications may facilitate additional use through the accessory pathway. Pronestyl or amiodarone may be considerations; however, if this patient requires immediate intervention, cardioversion will be the best bet. Digoxin is a poor choice of agents for WPW. Our treatment will be limited. This patient will require a comprehensive workup and if possible a catheter placement. We will need to be careful with medications as there may be underlying hepatic and renal issues. I would attempt to limit pre-hospital pharmacological interventions. Take care, chbare.

Condolence book is open at flightweb: http://www.flightweb.com/condolences/index.php?cid=53/ Take care, chbare.

Welsh, I think some were a little taken back with the "shame on you" remarks. Many Americans want health care reform and coverage and are not against these concepts. However, what just passed could be dangerous for the United States. We have no money, we are trillions in debt, we are already funding two battlefields and sending out billions in aide to other countries while we continue to take money from other countries such as China. Potentially adding trillions more to what we owe when our economy sucks could potentially bite us on the ass. We are doing this to extend coverage to 30 million or so people at the cost of potentially causing our country to go under. We should focus on conservative changes such as decreasing cost and tort reform instead of drastically changing everything with a concept we cannot afford. The US is in a bad way right now. Take care, chbare.

I'm all for giving everybody health care; however, I'm still a little confused about where all the money will come from. Best case scenario being, Obama has a cash crop of blooming money trees. Otherwise, I would refer back to my prior post and the emphasis on Rosetta Stone. Take care, chbare.

Well, to be fair we do pay for mail service. In fact, people, regardless of their ability to pay, have to pay the same price for stamps and mailing packages. Take care, chbare.

In your humble opinion. Take care, chbare.

I am not sure. What do you consider an "allergic reaction?" I go by the literal definition relating to an immune response involving immunoglobulin E (IgE) mediation of mast cell and basophil activation among other mechanisms as the proper way to define an allergy (when considering anaphylaxis). Most everything else will fall under the umbrella of an adverse reaction. From evidence I have seen, postoperative complications including puritis, nausea/vomiting, and urinary retention in patients on PCA were significantly higher in morphine groups compared to fentanyl groups. Therefore, I could say with some confidence that the incidence of adverse reactions may be lower overall in patients who receive fentanyl. Take care, chbare.

I suggest the following to prepare for the potential consequences: Take care, chbare.

Want to consider tumor lysis syndrome. Take care, chbare.

Fentanyl is not associated with histamine release unlike morphine. Therefore, fentanyl is less likely to cause hemodynamic changes and may be better tolerated by people with compromised hemodynamics such as trauma patients. Take care, chbare.

How much oral meperidine has this patient been taking? Oral meperidine typically undergoes fairly extensive first pass metabolism and a metabolite known as normeperidine is produced. Only problem being, normeperidine is rather neurotoxic and can cause seizures. Take care, chbare.

I am not sure that translates well to the United States, however. RSI was used as an earlier example; however, paramedics do not perform RSI in New Mexico save for special skills qualified services (flight services). Therefore, we are not actually asking for a highly advanced provider when looking at having paramedic availability in certain areas. Specifically areas that can support a college, state fire academy, and state police academy. This is even more interesting because a little town about an hour south of Socorro, of maybe 8,000 people that has a five bed ER and highly limited medical facilities manages to employ paramedics. Take care, chbare.

We are talking about a city of 10,000 people, a city that supports a college and the state fire academy in addition to the state police academy. When patients present to the hospital, there is an RN somewhere in that emergency room, I do not think it is too much to ask to have paramedic level of care available outside the hospital. Also remember that the paramedic in the United States, specifically New Mexico can be completed in about one year versus how long for the Australian ACP? The New Mexico intermediate can be completed with less than 300 hours of total training. Therefore, if patients require any modalities beyond the EMT-I scope of practice, I am not sure how that level of care is delivered. With the variable weather and many days of dust storms with low visibility in southern New Mexico, you cannot always rely on air-medical evacuation. With no specialty services in Socorro, patients requiring intervention such as cardiac resources have to go to Albuquerque somehow. Heparin and nitroglycerine infusions are well beyond the NM EMT-I SOP, therefore, how are these patients transferred? Take care, chbare.

I was not aware there was a paramedic in Socorro. Socorro has always been this way and I can only imagine the culture that exists in the EMS community. It is pathetic and embarassing that a community that size does not offer a paramedic level service ( about 10,000 in Socorro proper ). I live in a smaller, poor border town, and the fire department here at least offers paramedic level care to the public. Good luck if you push for changes, you face an uphill battle. You will most likely have to deal with a shit storm after putting your name out here as well. Change will only occur after sufficient public outcry. However, New Mexico is not the most progressive state. Good luck mate. Take care, chbare.

I think the take home point is that you cannot accurately deliver exact doses and flow rates with watch the drops methods. Like Vent, my partner and I often find ourselves mixing our own infusions and utilising our own pumps to deliver infusions other than isotonic crystalloids that are up for maintenance or rapid delivery of blood products. I am aware of some videos where physicians swear by and utilise drip methods to infuse a wide variety of infusions. This is suboptimal in a setting where we access to pumps and syringe drivers that can deliver doses very accurately. Clearly, mistakes can occur and a pump is far from fool proof however. The stories of people joking about eyeballing infusions makes me cringe. Ruff, IMHO we should not be eyeballing these kinds of medications. Fiznat, you can expect to pay several thousand dollars for a new Alaris Minimed pump. Take care, chbare.

Rock Shoes, I am such a fan boy, I am willing to see what actually comes out. However, my initial negativity is based on what has been put out by Apple. Apple is saying this is going to be a revolutionary Internet experience, yet we will not have flash? Apple is putting a 1 Gig processor into the iTab, yet we will still have an iPhone OS that cannot multitask? Apple has the ability to address these issues and the technology can easy support fixing these and other issues. Therefore, I feel like Apple does not want to address these issues. My fear is Apple will pull another iPhone on us by releasing a new updated iPad after raking in money from all the sukkas who bought the first generation device. I understand the need to make money, but Apple is doing well and they would be smart to keep the fanboys happy while putting out top notch products. The current iPad is not top notch when considering what Apple is easily able to do. It's sad, because what I've seen of the iTab book store is impressive, and the integration of keynote into the iTab looks like an incredible experience. I guess I was really expecting something that would set the bar, especially with all of the iTab bloviating that has been going on. Take care, chbare. EDIT: Another double post, WTF?

I feel for you bro. Had the same problem occur about a year ago. No injury, just a spontaneous situation in my case. I'll write it off as poor protoplasm. You need to work with your doctor; however, many people can recover. With exercise and physio, I do fairly well and continue to work and I do not take any pain medication. Having chronic pain has been an adjustment however. With that, I have come to realise my days of pulling people out of cars and lifting them into an aircraft are over and I am in the process of reinventing myself. Back in school in an allied health programme. Currently looking at sleep medicine and/or diagnostics. It sucks being a poor college student and commuting two hours one way for clinicals; however, we need to do what we need to do. Take care, chbare.

All I have to go on at this point are Dr. Cowley's words, and from what I have read, he had specifically stated a time frame on one hour based on earlier evidence as noted in my prior post. While it may have been a good marketing slogan, I do think Dr. Cowley believed in the concept and did what he thought was best for the patients of Maryland. In retrospect, getting critical patients with uncontrolled hemorrhage to the OR ASAP is still critically important; however, the specifics of modalities we use today were not in place. I suspect, our modalities and theories will be different 40 or so years into the future. I am not faulting the concept at the time; however, I like other people on this forum am faulting the modern provider for holding onto this concept. Take care, chbare.

I always wondered if Dr. Cowley was being figurative as opposed to a literal golden hour. However, I have seen quotes where he specifically stated sixty minutes. The evidence for his statements appears to be based on reports of mortality from French military medics during world war one. Clearly, not the greatest evidence and during the late 1960's when he began to coin this golden hour concept, we really did not have solid trauma systems and good information tracking and gathering mechanisms in place. Even now, it has taken decades for us to fully appreciate the medical lessons from the Vietnam conflict that was in full swing during this time. In fact, we have revisited evidence from as far back as the Crimean war and have found uncontrolled extremity hemorrhage being a major problem. I remember being taught to load patients with crystalloids as an Army medic during the 1990's and strict adherence to 3:1 resuscitation was almost a standard of care. In fact, in many areas, you were negligent if you did not have at least a litre on board prior to ER arrival. Something about humanity makes rewiring these dogmatic concepts very difficult. We like to latch onto these concepts and hold on for dear life. It occurs in many other areas as well. I always like to utilise the field of physics because it is an "academic" field with highly educated people that have also been tempted to hold onto past concepts. When relativistic theory (something that we now utilise to make the GPS system work) hit the scene in the early 1900's, there was much reluctance to let go of the Newton dogma. Then, the master mind of relativistic thinking was hesitant to let go of his thinking as a new period of quantum theory hit the scene. I imagine the string theorists of today would be reluctant to let go if a breakthrough were to occur. It is difficult to let go of concepts that are simple and intuitive. The golden hour theory as I will call it is simple and easy. Give lots and fluids and make a mad rush for the OR. While intuitive, it may in fact not be the end all as we well know. I actually find the new age of resuscitation rather non-intuitive. We limit fluids and even surgical intervention. With the new damage control resuscitation techniques, we are taking people to OR and simply controlling hemorrhage without complete repair, then sending patients back to the ICU for additional stabilisation, and performing revision surgery at a later time. In addition, it is my opinion and my opinion only that Dr. Cowley was pushing to institute a HEMS programme in Maryland and the catchy phrase of "golden hour" did go over well with both the medical and lay community. Therefore, part of me will always suspect that the term "golden hour" was pushed foreword with goals other than solid evidence based medicine in mind. Take care, chbare.