chbare

Or we could look at agents that are much better for the task of RSI induction agents. Currently, no better agent than etomidate exists. It acts very quickly (one arm brain cycle essentially), has a predictable duration (100 seconds for every 0.1 mg/kg dose), and it has no effect on hemodynamics. The next best would be ketamine IMHO. We must remember that sedatives such as Diprivan and diazepam do not provide analgesia. Sedation and analgesia are different topics. So, I typically use etomidate, then follow up with diazepam and fentanyl. Take care, chbare.

I also would like to emphasize that the 83K is only tax free if you spend a significant amount of time OCONUS. That means no bumping the nasty with the wife in the United States when you take leave. I learned that one the hard way. I would also emphasize the fact that the operational environment in Iraq or Afghanistan (where I worked) is significantly different from anything that you have ever encountered. Many of the medications have different names and routes, any medications are used that you would never see used in the USA ( Isosorbide and sufentanyl infusions anybody), and the operating tempo is quite different. In addition, a working knowledge of primary care, medical intelligence, epidemiology, and diagnostics is mandatory. Depending on your job, operational experience is a must as stated above. I was not an "operator;" however, we still worked in the non-permissive environment and spent much time behind the wire, therefore operational experience was still needed. Good luck and as stated research and have a good idea of what you are getting into. I learned valuable lessons the hard way. This is a money driven business, and with money comes all the various problems that accompany such a concept. Unfortunately, it's pretty tough dealing with said problems when you need to worry about planning a route of travel, kidnapping, firefights, IED's and VBIED's. EDIT:Welcome to EMT city DCHealth. Good luck and take care, chbare.

That is actually a very small dose for the purpose of RSI. You may skate by with a minimum of 0.1 mg/kg. However, this will still be ~7mg in the "average" adult. With that, the slow onset and hemodynamic implications of midazolam do not make it a very good candidate for RSI. Take care, chbare.

Unfortunately, an initial dose of 5 mg of midazolam for a 70 kg patient is rather suboptimal. A typical recommended dose for midazolam induction is 0.3 mg/kg. How many people do you see giving 21 mg of midazolam IVP? Therefore, many patients are being under-medicated. In addition, 21 mg can effect hemodynamics in the most "stable" patient. Of course, if we are looking at RSI, how "stable" is our patient? One area we often overlook is good ventilator management. We frequently run for the drugs when out patient even twitches. However, we need to ensure we are meeting our patients needs prior to going down the route of halcyon dreams and neuromuscular blockade. One thing I have seen and have attempted to correct is inadequate flow. We are taught an I:E of 1:2 is "optimal." Therefore, I have seen providers run adult vented patients at flows as low as 17 lpm to ensure they have that perfect 1:2. Therefore, meeting your patients demand and attempting to facilitate good patient to ventilator interaction is paramount. Infusions are a consideration and guidelines are all over the place. I have run midazolam infusions at 10 mg/hour and given fentanyl boluses as needed with good success. Mixing 10 mg in 100 ml makes for easy math. Ketamine is a consideration; however, you will need continuous infusions for prolonged transport and secretions along with increased sympathetic tone are considerations. Fentanyl infusions of say 1 mcg/kg/hr with boluses as needed are considerations. Some services carry diazepam and lorazepam for this purpose as well. Diprivan is a very fickle medication and precipitous drops in blood pressure are common. Additionally, you typically have to give very large doses in the stimuli rich environment of the transport environment. As it is, I have take care of many ICU patients who required vasopressor infusions to maintain blood pressure because of the high doses of Diprivan. It is also thick, milky, and loves to make bubbles that drive our minimed IV pumps crazy. I typically use diazepam and fentanyl. For a typical 30-45 minute flight with the "generic" otherwise healthy adult patient, it is not uncommon for me to give 300 mgc of fentanyl in divided doses (of 100 mcg) IVP and 20 mg of diazepam (in doses of 10 mg) IVP. Take care, chbare.

They are catching on in the southwest as well. Phoenix is pumping them out with ever increasing numbers of destination therapy patients. The Heartmate II seems to be the device of choice. Many EMS considerations such as non pulsatile blood flow, CPR, electrical therapy, and even giving nitroglycerine.

Strange, LVAD patients who are DNR. They must be destination therapy patients. Take care, chbare.

Did you ask these paramedics to give their reason? When you ask somebody to articulate their stance and give evidence to support their claim, their argument is deflated. There is no standard because there is no standard. There exist no compatible issues, therefore the decision is based on protocol and sound clinical decision making. Unfortunately, it would seem students are taught " if you give this hang that" cook book medicine. Therefore, taking decision making out of the equation and simply telling people to give this or that is easier than taking the time to actually explain how these fluids work. Take care, chbare.

That is a consideration; however, consider the following: D5W has 5 grams of dextrose per 100 ml. An eight ounce glass of cranberry juice has about 36 grams (~15 grams in 100 ml) Therefore, you would have to run your D5W at a rate of 300 ml/hr just to give the dextrose of a glass of juice. While this is doable, I am not sure that doing this is all that helpful for transport times of less than 20 minutes. In addition, once the dextrose is utilized, free water is left behind. This leaves a rather hypotonic solution behind. Not the greatest solution for already swollen cells, cerebral edema, or stroke patients. Since stroke should be on your differential list for altered mental status, even in hypoglycemic patients, you will need to be very careful and utilize good clinical decision making if you want to go down this route. Take care, chbare.

Does it really matter? If it's a choice between using NS or D5W as a vehicle for D50, I cannot see where the conflict is coming from. If we are talking about tonicity, electrolyte imbalance, and solvent/solute shifting and the implications for patients with various conditions, we have a discussion. However, I dare say the topic at hand does not relate to such concepts. Seems like the "I was told this and he was told that" situation. The best thing to do is ask the following questions: 1) What was the reasoning behind using NS when you were taught? 2) What was the reason for teaching D5? If the answer was something like,"because they said or medical director preference" a comprehensive argument or discussion does not exist. Take care, chbare.

What do you have? The heart mate II is the most popular device in my area. Take care, chbare.

I can feel Vent's presence. Unfortunately, you can really screw somebody up with a ventilator. I am not familiar with this specific ventilator; however, I suspect it may actually be safer to bag these patients in many cases rather than attach a rudimentary device without the benefit of pressures or graphics. Take care, chbare.

Epic video! Take care, chbare.

Take care, chbare.

There ya go buddy! Cheers! Take care, chbare.

Yes and no. If you are unsure, I see no problem with a cautious approach and supplemantal oxygen. However, sustained exposure to high fractions of inspired oxygen can lead to problems. You can have nitrogen washout and collapse of the alveoli, you can have damage to type I and type II alveolar cells, and even free radical concerns. Therefore, I can see your point; however, health care does nor stop at the door to the ER. Therefore trying to look at the big picture is helpful. Take care, chbare.

Hey guys, we also need to appreciate the difference between oxygenation and ventilation. Putting somebody on a non-rebreather is not going to change their carbon dioxide. Talking about chemoreceptors and respiratory center activation, we need to realize acids typically tell us to breath. When you hold your breath, the urge to breath is due to carbon dioxide levels increasing. Therefore, I cannot see any harm in the short term by placing a person who is breathing rapidly on a NRB if we are unsure of the cause. However, assuming hyperventilation syndrome is a dangerous mistake without solid evidence to back it up. I have seen many anxious diabetics in DKA breathing rapidly to compensate. You assume a rather benign condition and have them breath in a bag, you just opened a big can of fail. Many other pathological causes can cause "hyperventilation" and must be ruled out. ( overdose, pulmonary embolism, trauma, metabolic acidosis to name a few) Take care, chbare.

http://features.csmonitor.com/globalnews/2009/10/07/top-5-blunders-of-somali-pirates/ Take care, chbare.

Early afternoon with good weather and visibility. Two patients that weigh about 60 kg a patient. Extrication of one patient in progress. Volly fire department on scene providing first responder care and extrication. You are 60 minutes by air to the trauma center and 10 minutes from a county hospital with minimal resources; however, they have a general/vascular surgeon on call. Scene and LZ is secured and you land without incident. Two patients: Patient Y: 19 year old female driver is trapped in the remains of the car. You not extensive damage to the car. The patient is unresponsive. Patient X: 19 year old female front passenger was ejected from the vehicle and landed about 20 feet from the car. Patient is unresponsive and it look like the first responders have placed an LMA and are bagging her rather aggressively. Non-patient M: 20 year old female who was a restrained back seat passenger is available to answer basic questions. Take care, chbare.

You are a member of a two person flight crew on an EC-145 configured for two patients and you have been called to the location of a one car rollover with ejection and two patients. Take it away. Take care, chbare.

My nursing clinical experience was not flexible. We had practicum on Tuesday and Wednesday. We had 16 hours of practicum a week and another 4-8 hours of pre-clinical work per week. The exception was labor and delivery where we were on call and had to continue the rotation until we did a delivery. My RT clinical experience will not be flexible either. We have practicum on Monday and Wednesday, with the exception of the summer session which is about 10 hours a day for five days a week from what I have been told. Vent pretty much nailed the other concepts and would be a better resource if you consider the RRT route. I would not suggest settling for CRT if somebody tries to persuade you to take the shorter route. With increased competition and focus on critical and special care, the role of the CRT in many places is going away. Go RN or RRT and if you have a BS program close by and get accepted take the opportunity. I wish there was a BS program in my area. Take care, chbare.

OK then. I agree with the general consensus. I also agree that a for credit course that transfers should be taken. Let me explain the reaction I received to my experiment. You can most likely guess the outcome? Actually, the outcome was interesting: As can be expected, I received strange looks as I handed out copies of the periodic table. Even more strange looks when I started with my review of the basic atomic structure and an overview of the periodic table (Atomic Number, Mass Number, Relative Mass, Group/Family, & period). Then, I asked a question about labs. What about sodium, chloride, or calcium? What is a miliequivalent? I explained the concept of a mole and how it relates to the relative atomic mass. Of course, I explained this in regards to the concept of moles versus equivalents and 1000th of an equivalent. It was neat to see people understand for the first time that electrolyte lab values actually relate to a real and understandable number of atoms. The really neat part occurs next: I then started talking about electrolytes. What is an electrolyte, ion, cation, and anion? I took people on a field trip through the periodic table. First, we looked at sodium. I talked about the octet rule and how atoms want to have 8 electrons in their valence for "stability." So, we dissected sodium. Na--> Alkaline Earth Metal--> Atomic Number 11 ( 11 protons & 11 electrons)--> Period 3 (three energy levels of electrons) --> Group 1A (1 electron in the outer valence). Then, we discussed what happens when sodium becomes an ion within our body. I explained the loss of one electron to satisfy the octet rule, hence the +1 charge. I proceeded to do this with class participation on the popular positive and negative ions, emphasizing the fact that metals loose and non metals gain and the marriage of ions and ionic bonds. After explaining this, one paramedic stood up wide eyed and stated "my God I get, I get it now." Apparently, he had always wondered how ions worked and wondered about the concept of hydrogen and calculating PH, labs, and the actual meaning of the numbers. The insight that he gained that moment was a wonderful thing to experience. I was able to just brush on the basics of covalent bonds and electron sharing, and the carbon atoms' unique place and relationship with other atoms such as hydrogen. Clearly, important concepts to understand when considering any organic molecule or structure such as benzene rings and hydrocarbons. This clearly applies to pharmacology and human biology at a supra-atomic level. Therefore, I do think that a chemistry requirement is very important for a variety of reasons. Do this mean I think paramedic students should study the behavior of elementary particles and know how many quarks and their spin level within say a proton, or realize that elementary particles may actually be strings that require 11 dimensions of space time for specific types of vibration? I think not; however, a rudimentary understanding of basic properties of matter at the atomic level may make understanding concepts at the cell, tissue, organ, and organism level much easier and much more complete. All of this is anecdotal and IMHO of course. Take care, chbare. Edit:" y" --> "e"

My program is an AD program that is about 27 months long. We go through the summer. Clinicals start second semester and are two days a week for three semesters. In addition, we do a five week ventilator course over the summer followed by several weeks of straight clinicals, then into the second year. I did not go through school during the summer as a student nurse; however, we spent several hours a week in pre-clinical work. All in all, we will have 1,000 hours of clinical experience. This is about as many clinical hours as my nursing program. Take care, chbare.

Pre-req courses are very similar for both programs. Nursing school is full of busy work while RT school seems straight foreword but more technical and physiology based. Nursing school has a broad focus, where as RT school seems to have a narrow but indepth focus. On line nursing programs seem to be the latest and greatest thing, online RT programs do not appear to be as popular. Pay for both providers is highly variable, RN's will make a bit more; however, this gap is not wide and does not exist in some areas. I am not sure your plan to attend school for promo purposes is a great plan. Both programs are full time and not piece meal class here and there educational experiences. I am a RT student, and I am in class five days a week. My shortest day is four hours in class with my longest being around six. In six weeks I had written three large papers and completed several large reading and homework assignments. In addition, a four page APA article review is required each week. So far, I can say the commitment is similar to my prior experience as a nursing student. Take care, chbare.

Fibrinolytic therapy is not really indicated at this point. Cardiogenic shock associated with MI does not typically respond well to fibrinolytics. Additionally, this patient will be on his way to an intervention soon. CPAP may actually worsen his condition with increased intrathoracic pressures. A statement that carry with me applies: What is the enemy of good? Better is the enemy of good. This guy is hanging tough for the moment, he is doing good in spite of the underlying problems. Sometimes, we make the situation much worse in our pursuits of better. Nothing much we can do for his regurgitation or RVI at this point. Perhaps consider judicious fluid administration. The guy is awake with rather acceptable vital signs given the fact he could be much worse. Do you really want to screw with that? Benign neglect is the word of the day until the surgical team arrives. Take care, chbare.

I typically teach a pathophysiology course as part of critical care orientation, and I decided to change the presentation somewhat. I was able to lengthen the class a bit and I decided to add in a basic chemistry component. (Basic atomic structure, the formation of ions,(cations and anions), basics of ionic bonds, basics of covalent bonds, the mole, Avogradro's number, and a couple of other basic concepts.) The results of my class were quite interesting and I will discuss them later. However, what do you guys think? Is chemistry important, did you have chemistry, can you relate chemistry to critical aspects of your role as an EMS provider? I am really looking for productive conversation, and my intent is not another EMS education sucks thread. Take care, chbare. Edit: poll clarification.