chbare

If I read the original post correctly, this thread is not about patient death per se, but rather about the consequences of making a mistake? What exactly is the error in question? Take care, chbare.

Another thought that can give you great experience is working in the ER and/or ICU as a paramedic or technician. You will gain valuable experience if you nab one of these positions. Take care, chbare.

No, nursing school is the model for good education and new nurses are educated to the highest standards of progressive medicine and current evidence based practice. Take care, chbare.

Watch your tongue. You may wake up to find an aircraft carrier off your coast with motherland hate speach like that. Well, maybe in another three years or so. However, I am still not sure why we continue to use pounds, quarts, yards, miles, and gallons? I use SI at work, SI in school, but a totally bizaar system where the units have no common conversion factor while at home. I guess we are that much better than you all for keeping two systems sorted. Take care, chbare.

You are on the right track. Atoms bind and interact through two broad categories: Covalent bonds & non covalent bonds. When we talk about sodium chloride, we are talking about a type of non covalent bond known as an ionic bond. Let's explore this concept of an ion. Do not worry, I intend to bring this back around to the question at hand. Atoms are composed of three "gross" parts. You have neutrons and protons in the nucleus and electrons outside of the nucleus. Electrons are negatively charged and protons are positively charged. Therefore, an atom in it's "natural" state will have the same number of electrons as protons in order to have a neutral overall charge. Unfortunately, electrons are fickle and like to have an arrangement that is "stable" The electrons in the outermost "shell" (this is called the valence, and we call these electrons valence electrons) of the atom want to meet what is called the octet rule. This is, atoms are very happy when they have eight electrons in their valence. (Exceptions are few and far between and include elements like hydrogen that only has 2 electrons in its valence; however, the first shell can only contain 2 electrons, therefore it is full and considered stable.) So, in an ionic bond or ionized situation, atoms either gain or loose electrons to meet this octet rule. I want you to look at the table below: The periodic table is very helpful with understanding these concepts. The periodic table is roughly divided into horizontal rows called periods and vertical rows called groups. The information from this arrangement is quite helpful. Let's look at sodium: Sodium is Na on the far left of the table. The number above Na is called the atomic number and this tells us how many protons are in a sodium atom. The atomic number is analogues to a fingerprint. Every element will have a unique atomic number. So, if sodium has 11 protons, it must have 11 electrons. Now, let's look at period and group. If you count down, sodium is in the third period. This means that sodium has three shells of electrons around it's nucleus. While it is not stated, sodium is a group 1A element. This means that there is one electron in sodiums valence. Therefore: the electron arrangement would look like this: first shell (2) (most that can fit in the first), 8 electrons in the second, 1 electron in the third. So, for sodium to meet the octet rule, what has to occur? You may have guessed it, sodium looses the electron in it's valence, and now the octet rule is met. So, if sodium looses a negative charge (electron), the overall charge of sodium is now positive. This is why sodium is positively charged as an ion and why it's called a cation. Anybody want to work out what happens to chlorine when it becomes ionized? Take care, chbare.

Right, specifically why does sodium have a +1 charge and why does chloride have a -1 charge? What determines a positive ion (cation) versus negative ion (anion) and what dictates the actual charge? I will leave the transition metals out of this discussion for the sake of simplicity however. Take care, chbare.

LOL, Caravan, you are quite spoiled. Try a Kodiak or the back of an Antonov 26 ( an 26) that was just cleared of boxes of fruit. I worked with South African doctors who agreed on the an 26's official name of "ghetto plane." Take care, chbare.

Unfortunately not. Most of what I am doing right now revolves around finding limiting reactants, reaction rates, calculating theoretical yield and percentage yield, thermodynamics, gas laws, and entropy/enthalpy calculations. However, many of these concepts require conversion of moles to grams and visa versa to plug the proper values into the formulas or dimensional analysis. So, it got me thinking about a common medication we often administer without fully appreciating what the numbers on the bag mean. Take care, chbare.

No problem guys, we will talk about individual concepts, then hopefully put it together into a cohesive format. So Far we know: 1000 mEq = 1 Eq, 1 Eq = Mole/charge, Mole = Avagadro's number or 6.02 * 10 ^23 atoms/molecules Further explanation: 6.02 * 10^23 is what we call scientific notation. When numbers are too small or large for conventional context or understanding, we put them into this format. We essentially make a smaller decimal number and use a factor of 10 to describe how many times we multiply that decimal or whole number by ten to reach the actual number. For example: 1,000 would equal 1.0 * 10 ^3 ( If we multiply by ten, three times, or move the decimal to the right three spaces, we have the actual number) Likewise: 0.001 would equal 1.0 * 10 ^ -3 ( Very small numbers less than one use a negative value, or we move the decimal to the left to obtain the actual number. Therefore, you can see the 6.02 * 10^23 is so incredibly large that understanding it in a conventional context and writing the entire number out is unreasonable and inherently difficult, if not impossible for most people. The next thing to describe is the concept of charge? Take care, chbare.

Good: specifically, a mole is 6.02 * 10^23 atoms of an element or molecules of a substance. Therefore one mole of O2 would have a weight of ~ 32 grams. Ok, so what about moles of saline? Take care, chbare.

Not exactly, but many people think this. A mEq is derived from equivalent. 1000 mEq = 1 equivalent. The definition of an equivalent is moles times charge. So, let's start at moles. What is a mole & how does it relate to the question at hand? Take care, chbare.

Thought I would do something challenging, possibly fun, and a reminder of just how complex something we take for granted every day can be. Anybody with a degree in chemistry, biology, engineering, or physics need not post. Okay, here goes. Normal saline, we all give it, we all talk about it, do we really know it on a fundamental level? So, take a look at a liter of the ever present 0.9 % normal saline. What does it say on the bag? Do you see something about milliequivalents? What does this mean and can we do any meaningful calculations to better understand this common medication? Take care, cbare.

Additionally, I would like to emphasize that yes etomidate is well known to cause transient adrenal suppression after one dose. However, I am unaware of any evidence that definitively says etomidate leads to poor outcomes in patients where this may be a problem. There are studies and allot of talk; however, the fact remains that etomidate is still a viable agent. While some providers has started to stress dose people with steroids, I am unsure if this practice actually improves outcomes. The thought that steroids lead to up regulation to adrenergic receptors in septic patients appears to be falling out of favor and may not be effective. Regarding "waking"people up to allow for negative pressure. It is a good thought in that the ultimate idea is to liberate the patient from the ventilator as soon as possible. Clearly, spontaneous "awake" trials are performed in the hospital prior to the decision to liberate and ultimately extubate. However, the transport environment is tricky. I think the practice of keeping patients light needs to be considered carefully. If you have even the slightest patient/ventilator dys-harmony, having an awake patient who is not interacting well with the ventilator is a setup for disaster. Many of the transport ventilators are simply not able to physiologically meet the needs of many patients, and many providers are not keen in this area of management. In conclusion, good concept with the caveat of having a capable provider and ventilator, therefore it is not as applicable in the transport environment. Additionally, many patients who are intubated at point of care have conditions where physiological strain could be quite harmful. Head injuries, cardiogenic shock, and septic shock are all conditions where you do not want a patient awake with increased oxygen consumption and demand. Therefore, I tend to keep my point of care patients rather heavily sedated with liberal analgesia. I am aware of my limitations as a provider and the limitations of my equipment and feel this approach is safer than attempting to keep my patient "light" while attempting to setup perfect patient/ventilator interaction with a crossvent four. Take care, chbare.

This whole situation seems odd: words such as "tramp, " "toy boy latino," and a poll where an answer of I know it's ok to cheat really seem rather out of place. If this is true, the situation is truly tragic; however, the tone of the posts really seem strange and it does not quite sit right with me. I agree with Ruff, it this is a true situation it is tragic. If the deaths are true, then friends and families on all sides are involved in a tragic situation. Death does not typically occur in a vacuum and many people are effected in the aftermath. Take care, chbare.

Take care, chbare.

Hey guys, I also want to emphasize SA is talking about care in an environment so far removed from what we know in the United States, that making a comparison is nearly impossible. If you have never experienced the horrors of some of these places, you really cannot adequately appreciate the profound differences. Therefore, I am not sure I would go so far as to call the doctor in question incompetent as much as simply not having access to resources? Then again, the patient was placed on CPAP, so the hospital in question had access to this resource. I tend to agree with Vent that the prognosis for this kiddo is quite poor. I understand what you mean SA, I was forced to leave patients to die a miserable death during my time over seas because of lack of resources, qualified providers, and cultural beliefs that punish even the most innocent kids. Take care, chbare.

I am going to give SA the benefit of the doubt here. Knowing what I know about some of the government run facilities in South Africa. Take care, chbare.

Damn South Africans and you're nursing sisters. I did a double take when I first experienced that term. One thing we must appreciate is that a delta exists between EMS in the US, Canada, & South Africa. Additionally, a rather large disparity can exist between government and private facilities as already stated. Therefore, it will be difficult for me to say what should and can happen at the level of policies and procedures as they pertain to EMS versus different South African hospitals. Additionally, as I understand the concept of "medical direction" does not exist as we know it in South Africa. SA EMS providers specifically B-Techs and the like are not necessarily strictly bound to a "medical director" per se. Please correct me if I am totally off. Therefore, I will focus on the medical care: Do you have any additional information? Where there labs, radiographic findings, and any history and physical exam information you could provide us? A two month premature infant in respiratory distress can literally have a plethora of problems. The pneumothorax could have been caused by multiple concepts as well What about your assessment? Head to toe assessment, lung sounds, abdominal assessment, heart tones, information for the family? Take care, chbare.

Problem being, the I99 level of education is rather minimal when you look at all the drugs and skills at their disposal. They can do allot; however, does this actually mean the education they receive prepares them for this scope of practice? This goes back to my chemistry thread. If you do not have a real understanding of the fundamental sciences and how things work, should you be performing interventions that actually effect these fundamental concepts? Rather significantly in some cases. The point is moot as somebody pay grades above me thinks the I99 is roughly equal to a paramedic and should transition into the medic role with some classroom bridge training. I actually covered these national SOP changes several months ago in a thread with links to official sites and publications. Pretty scary stuff actually. Take care, chbare.

It's variable by area. Arizona is a mess as stated. In my area, EMS calling us is not so much a problem. However, facilities flying non-urgent cases such as a non complicated ortho case when their ortho doc does not feel like being on call and flying a person to a medical/surgical floor at a larger facility to have their gallbladder removed. The list continues and becomes more obscure; however, the point should be clear. Clearly, this is not the best resource utilization and quite costly. However, as stated, the bottom line in this business revolves around money. I suspect a great number of us would be in the employment line if HEMS was a properly utilized resource. Take care, chbare.

Actually, corneal injuries are quite common in unresponsive and intubated patients. It is not uncommon to keep the eyes closed during surgery or following a RSI to prevent corneal injury. Take care, chbare.

That is too bad. You should take the articles posted by ERDoc to your medical direction. It is inhumane to with hold pain medications for abdominal patients and analgesia clearly does not adversely effect the diagnosis of abdominal conditions. Teaching people otherwise is doing so against a large body of evidence that does not support such practice. Take care, chbare.

Fairly new evidence based thoughts out of the UK where many concepts are discussed: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2751736 Much of the immobilization hysteria in the United States boils down essentially to the following broad concepts: 1) Defensive medicine 2) Protocols 3) Ease of Movement Take care, chbare.

Thanks, this pain med issue is not a new one and a concepts that continues to plague the pages of EMS sites. It is sad and to see some of my colleagues who work in progressive areas cannot take the time to learn about progressive changes of the health care system. In fact, this pain medication myth is not a new concept, yet people continue to adhere to concepts that are decades old and quite outdated. Take care, chabre.

Actually, it is the other way around in my area of the world. We almost exclusively utilize etomidate for pre-hospital RSI. My choice of diazepam & fentanyl is personal and rather anecdotal. First, I have had sudden hemodynamic changes with conservative doses of midazolam. This is not something a person with a head injury, altered hemodynamic status, or altered cardiac status likes very much. Unfortunately, these three patient compose many of my RSI's. Not that I actually perform RSI that frequently. Therefore, I typically use diazepam and liberal doses of fentanyl. Most of my ketamine experiences are with conscious sedation for procedures. Typically, we will follow the dose of ketamine with doses of analgesics and benzodiazepines. Clearly, benzodiazepines blunt the possibility of an emergence reaction. Ketamine actually has both analgesic and sedative like effects by its self. However, there are many pitfalls to consider: -Ketamine is a cardiovascular stimulant: perhaps not a good consideration in patients in heart failure or MI. -Theoretical potential to cause harmful increases in ICP; rather dodgy evidence and in fact evidence that supports potential cerebral-protective benefits. However, it is still considered head injury taboo in the United States. -Emergence reaction and psychological harm if you allow the person to "wake up" without the benefit of benzos. -Increased secretions. Therefore, choosing ketamine requires additional agents and considerations. You will most likely need to combat secretions, monitor for adverse cardiovascular effects, and prevent emergence. While emergency may not be a big consideration for RSI, how are you going to know if you quickly push your NDNMB after the intubation and neglect to follow up with a benzo? At this point, I still advocate for etomidate as the quickest acting agent with less pitfalls than other agents on the market. Take care, chbare.