chbare

Funny, you guys remember when Cat Stevens was detained and hassled over some nebulous and ill defined information as far as I know? http://edition.cnn.com/2004/US/09/22/plane.diverted.stevens/ Now, people are saying they cannot act without credible information? So, Cat Stevens was on a watch list but this dude was not even after his father came foreword with information. In addition, I think the UK had pretty good info and was watching this guy closely. I call BS, this was a major screwup and heads should roll IMHO. Take care, chbare.

Strange? The first few weeks of my A&P 1 course consisted of a chemistry overview, a review of the common pathways, and the basics of cellular structure and function. In fact a rather popular A&P text book, the Marieb series covers this very material in the beginning chapters. However, it was not until microbiology/molecular biology that the pathways were covered in greater detail. Take care, chbare.

I agree with JPINFV. If at all possible, you need to take a dedicated for college level course in A&P. The traditional approach would include a full year or two semesters. In addition, each semester should include a lab. I understand a quarter system exists; however, the standard should be a course of study similar to what I described above. I am not a big fan of these eight week basic courses simply because the material is covered at such a basic level with gaps and even information that is watered down to the point of potentially hindering, I would not recommend such a route if other options exist. In addition, while some would argue, I honestly think taking a semester or more of chemistry prior to the A&P would be even more helpful. Understanding common concepts such as how molecules are formed, protein structure, chemical bonds such as the ubiquitous hydrogen bonding and many other concepts will ensure you do well in A&P. Unfortunately, I took A&P without the benefit of chemistry and much of the physiology became an exercise in memorizing pathways and words without any real understanding of the core concepts. Of course, to do well in chemistry, you also need to be comfortable with your math skills. You will also find the many dimensional analysis questions you solve in chemistry will be very helpful when it comes to medication calculations. Take care, chbare. I think JPINFV adds validity to the core concept of your statement. While he was a EMT-B, he was able to discuss complex topics with ease. Of course, now that he is a medical student, he doesn't shyte. Take care, chbare.

What I currently utilise. Take care, chbare.

Take care, chbare. Edit for color problems.

We need to ensure adequate oxygenation and we need to ensure a patent airway. If aggressive suctioning is required, so be it. We also need to remember that the urge to breath when holding your breath is not because you are hypoxemic or hypoxic. In fact, most people have a primary respiratory drive that responds to PH changes well before responding to hypoxemia. Therefore, I tend not to use breath holding or a set time in seconds so much as assessing the patient for any indications of hypoxia as an end point to suctioning. However, many sources do use 10-15 seconds as a recommended suction time. Take care, chbare. Joseph, you need to read through JPINFV's link.The King is not technically approved to be marketed as a rescue device for EMS. While it can be used as such, the FDA has not approved the King to be marketed for this role. I believe at one time only two devices could be marketed as such and they included the Combitube and LMA. These were the only two devices to have the AHA "alternative to endotracheal intubation" seal of approval as well. This may have changed with recent changes, however. Take care, chbare.

Negative pressure ventilation is still around. The following is an article from 1996 that is dated as far as current literature; however, many of the conditions and potential conditions that can benefit from NPV modalities are covered. http://www.erj.ersjournals.com/cgi/reprint/9/7/1531 The following is a newer review of prospective literature. It is actually somewhat limited for NPV when considering using NPV for acute conditions; however, it does appear that NPV could have a role. Clearly, I think a modality that helps the patient and prevents intubation has potential. However, I am not sure how NPV would compare to less invasive positive pressure techniques such as CPAP and BiPAP. I have even seen literature stating good results when patients were liberated from the ventilator by extubating and transitioning to less invasive ventilation techniques. As I remember, many of these patients did not undergo traditional spontaneous awake breathing trials. Therefore, I suspect it takes a massive pair to simply extubate and trust the less invasive modality to do the rest. I will try to pull the literature. Dr. Jeffrey Guy actually presented these studies in a recent podcast from his ICU rounds series. Free iTunes download. I will try to find the exact podcast. http://www.erj.ersjournals.com/cgi/content/full/20/1/187 Take care, chbare.

Thanks for the scenario. I am not too proud to admit I initially considered croup. Take care, chbare.

FBAO. Take care, chbare.

A foreign body obstruction should be ruled out, hence obtaining additional history if possible. Take care, chbare.

I agree with the additional history and assessment considerations. For example, sudden onset stridor is going to have different pathology considerations. I would most likely not go with salbutamol for an upper airway obstruction problem such as this kiddo. I would want to consider something like racemic epinephrine and ensure we are nebulising this medication properly, because unlike salbutamol, we want inertial impaction and deposition of the aerosol in the upper airway. I would agree, that at least a loading dose of a steriod will be indicated in this patient. While not an EMS consideration, this patient may benefit from Heliox therapy. If we are still looking at croup, I would not consider antimicrobial therapy unless we have other indications of a bacterial infection. We must remember, croup is typically a viral infection. Take care, chbare.

Or, the argument of the week. Sorry, could not help myself. So, were these guys actually on shift, break, or off shift? Take care, chbare.

It is actually very common in the Southwest. Tracking and cutting sign are critical skills that border patrol agents must master. Was really neat seeing them track and cut sign when I was working with a counter-drug taskforce some years back. Take care, chbare.

From what I understand, yes it does. I use the term FSW as if the diver were actually under X feet of water; however, diving gauges and decompression times are calculated based on pressure. So, depending on salt concentration, altitude, and even temperature, the pressure experienced may be different than the actual depth. When I use FSW in this scenario, it is more of a broad and nebulous concept. However, the real application is how much pressure was the diver experiencing? If the pressure = 300 FSW, then I simply say 300 FSW regardless of the actual depth the diver since I am primarily talking about Henry's law of solubility, the term FSW is the pressure that the diver experienced and not necessarily the actual depth. However, for the sake of simplicity I made both concepts equal in this scenario. A great question however. If you like math, the following link actually take you through calculating the difference. http://www.mindspring.com/~divegeek/altitude.htm In the real world, I think it is more important to obtain a good history if possible and transport the divers equipment and gas mixes and take people who were involved in the dive to the receiving facility because this will be a primary source of information for the said facility. As I stated, unless told you may not even know how deep the patient went as I would not even mess with diving equipment and would not advise people mess with the equipment. So, I would ask about; rate of descent, bottom time, deepest depth, gas mixes utilised, equipment utilised, ascent and adherence to decompression stops and times and any complications encountered in addition to the typical questions you should ask of every patient, then let the hyperbaric gurus figure out the details. Like you, my experience with diving related emergencies is limited. I have only one experience, and a strange one at that. I had a Spanish guy present to my remote clinic near Kabul. He had rather unimpressive signs and symptoms; headache, generalised myalgia, and sinus congestion. I tend to take very detailed histories and only found out about his hobby of technical diving when interrogating him about his social and personal habits. He had just returned to Afghanistan from a month of leave, during that time he did a 75 meter mixed gas technical dive simply for the fun. It had nothing to do with his current complaints; however, I must have asked him a hundred questions. Hope this helps. Take care, chbare. Edit: I have added a short video that does a down and dirty explanation of the gas mixes and even has an animation. This is a video about Nuno Gomex, a South African who holds the current technical dive open circuit record of just under 1,000 feet.

Curb your enthusiasm. Some of the episodes can be quite hilarious; however, I fear I would go straight to hell if I ever died watching some of this stuff. Take care, chbare.

I understand the transport concern and going by ground may in fact be faster depending on details I did not specify. Obviously, I can fill in the blanks and force the situation to go any way I want; however, the scenario required you to transport the patient regardless. As I stated earlier, I neglect some aspects to emphasize others and sometimes you have to have suspension of reality. For example, giving you the ability to interrogate dive computers and find out that heliox at 90/10 was mixed instead of trimix. I do not know how to interrogate the computer of a mk 15.5 rebreather, but I give out the information to emphasize teaching points. This is no different from letting you guys do CT scans in your ambulance. I absolutely appreciate a conversation about transport considerations, time, and safety; however, these were not concepts that I integrated into the original scenario. Sorry if you are dissapointed, I realize I cannot make everybody happy. If it will help, you could simply look at this as a straight ground transport scenario as the way to get the patient was less important than the investigation of the pathophysiology of the patients condition in this specific scenario. I try very hard to present challenging scenarios and I often emphasize points. Most of my case studies are presented in such a way. Rock shoes, you are correct. Take care, chbare.

You actually have no idea. We do not know how long the ground unit waited. However, I must impress that this is a time critical situation in some cases. While little time was spent on a comprehensive assessment, if there are any neurological problems, AGE is assumed until ruled out. This would be an emergency. While not part of the concept for my scenario, I do think discussing the transport considerations of dive emergencies is a good way to proceed. Rock shoes, you are very close. Helium does in fact have a very high level of thermal conductivity. In addition, gas inhaled from a tank will be quite cold at the depths mentioned. This changes with rebreather diving; however, this patient was in fact breathing open circuit. Take care, chbare.

No worries, even what I stated is going to vary quite a bit. Take care, chbare.

Sounds good, and this is a tough, unconventional, and potentially unrealistic scenario given the scenario background. However, I tend to present scenarios is a somewhat unrealistic atmosphere to emphasize points that can be lost otherwise. So, the reason we replace nitrogen with helium is to prevent nitrogen narcosis at depth. The exact action of nitrogen narcosis is somewhat of a mystery; however, it is a well known and even documented concept. Here is a video of divers who are "narced," clearly this is a potentially deadly situation: Helium, being a non reactive gas because of a concept know as meeting the octet rule. Without going over the top, this essentially means that the valence shell, or outermost orbital of electrons in the elements atom have met what is known as the octet rule. This is a very stable configuration and it makes these elements very stable and non-reactive under "normal" situations. However, a very strange thing occurs in people who breath high levels of helium at extreme depths. The numbers are all over the place; however, I think the current guidelines state that you should not breath heliox under 400 FSW. This concept is known as high pressure nervous syndrome, HPNS. (Old school people may remember the term "helium tremors.") We are not sure of the exact physiological mechanisms that cause it; however, it occurs in heliox breathing divers at extreme depth and can include; confusion, erratic behavior, and even seizures. We have found that even adding very small amounts of nitrogen to the mix can prevent the onset of HPNS. Hence, the reason for using trimix at deeper depths. In some cases, people have even experimented and used exotic gas mixes such as hydrogen and oxygen. Clearly, sofe safety concerns exist with these mixes. So, the scenario went like this:patient screwed up his gas mix, developed helium tremors, transitioned to trimix, then terminated the dive. Even though he ascended according to dive tables and compute, the bends can still occur and breathing the unexpected heliox may have been another factor to consider. One last question, why would breathing helium enriched mixes lead to hypothermia faster than other modalities? I hope you guys enjoyed this rather unconventional scenario. In school, we rarey spend much time on this topic, so I hope people found this to be informative and fun. Take care, chbare.

There is a fairly recent thread on this very topic. It is a very dynamic topic; however, I dare say that medicine has no real place in the hot zone save for self care and extracting team mates out of the line of fire. I worked with a team as an unarmed medical provider and advisor, I trained with the team; however, I would not be involved in the "operational" aspects. However, I dare say most of the job of the tactical medic should include "non-operational" concepts. Before even thinking about stacking up with the team with your weapon, you need to consider more important medical concepts: 1) Do you have comprehensive medical dossiers on each of your team mates? 2) Do your team mates have buddy and self aid SOP's? 3) Are your team mates trained in IAD's and self/buddy aid modalities? 4) Do you have a comprehensive MTA in place for your theatre of operations? 5) Have you met with local, state, and federal resources and have SOP's and mutual aid plans in place? 6) Do you have accurate weather and disease hazard information on file? 7) Do you have SOP's for working in inclement conditions? 8) Do you have work/rest rotation SOP's in place for extended operations? 9) Do your team mates have needed buddy/self aid equipment and SOP's on where that equipment is placed? 10) Do you have backup plans in place? Just to name a few "non-operational" but critical concepts to consider. Take care, chbare.

I would like to see Fireflies sources as the "radiation" exposure varies significantly from CT machine to CT machine. Additionally, the type of scan and the type of tissue scanned are considerations as well. For example, scanning in 5 mm slices is going to have a different exposure than scanning in 3 mm slices. However, doing the math goes something like this, a PA chest X-ray is one "shot" through the back to the plate. An acute abdominal series would include three "shots." "Average" background radiation exposure over a year is ~ 3 mSv "Average" PA chest = ~0.02 mSv "Average" Abdominal CT = ~10 mSv Take care, chbare. Oh yeah, before people start screaming for me to show the money shot: http://www.pueblo.gsa.gov/cic_text/health/fullbody-ctscan/risks.htm http://www.diagnosticimaging.com/dimag/legacy/db_area/onlinenews/2003/2003111901.shtml Take care, chbare.

Yes, there exists a small difference between fresh water and seawater, and even a difference between different areas of the ocean and the oceans and seas themselves. Take care, chbare.