chbare

It started with research he did in the military. They essentially let the pigs bleed out, did an open thoracotomy, infused a cold high potassium solution, repaired the wounds, infused a warm balanced solution, then resuscitated with blood products. (The solutions were based on solutions used to package organs for transplant.) Pre and post procedure, cognitive tests were performed on the pigs to identify cognitive impairment. As I said, they are now looking at large multi centre trials. So, we will see. Take care, chbare.

You can also download Dr. Guy's podcasts free from iTunes. The most interesting podcast is called ICU Rounds. Much of it is directed at residents, therefore I suggest you have a good foundation of A&P along with a working knowledge of how studies and EBM applies to clinical practice. Definitely not like picking up your favorite copy of "JEMS." The truth about all this permissive hypotension is that we are not quite sure of the optimal resuscitation modality. There are many new studies in the pipe line and the next decade will most likely be exciting. Anybody go to the SATNET conference this year in Tucson Arizona? I am just back from this conference, and there were several physicians commenting on resuscitation, EBM, and head injury treatment modalities. Much of it is a crap shoot. If anybody knows a Dr. Peter Rhee, you are most likely aware of his "suspended animation" research on pigs. In addition, a large multi centre study is in the works. So, we will see how things pan out. Take care, chbare.

Not sure I am making the never come back from Iraq ( or whatever, insert, third world...paradise )and boozer connection. I am not the smartest dude in the world; however, I think other members are looking at this situation with the following rationale: hmm it's rather strange for a mom to cruise down the wrong side of the road and crash into traffic buying the farm in a blaze of glory. Dramatic, yes. Unusual, absolutely. So, curious minds want to know why or how somebody could do such an unusual thing. Then comes this toxicology report. THC & it's metabolites in the blood stream along with a blood alcohol that is twice the legal limit. I am no police officer; however, if I was, I would consider that a clue. Nothing personal against these people; however, it's pretty easy connecting dots with some types of information. You do not want people calling you out on drug use, it's best not to do those said drugs. Otherwise... Take care, chbare.

Decreased sounds are not the sole reason for placing a dart. In addition, I dare say it would be unusual for a patients own respiratory effort to cause a tension pneumothorax. Positive pressure ventilation, a different story. Add into the mix an awake, alert, and non labored patient, and I say absolutely no indication for decompression existed based on the story presented. Even if a pneumo was present, many pneumos will resolve without any specific treatment beyond monitoring, rest, and follow up. Looking at the studies actually reveals that many people with out pneumos are darted and in many cases the needle fails to even enter the thoracic cavity. Especially with the anterior 2nd IC approach. You also have to consider potentially hitting critical anatomic areas like a subclavian vessel when you consider placing a dart. Not a benign procedure by any definition. Take care, chbare.

Actually, some of the remote clinics I covered had alternative airways and an AED as part of the resuscitation kit ( No setup for laryngoscopy ) In fact, in some situations, where resources were limited, time was limited, and light discipline was a concern, alternative airways were considered a primary option. Take care, chbare.

Vent, absolutely a great point. Pre-hospital intubation because the patients clinical course may include a trip to the OR is simply not a good argument for the said intubation. Unfortunately, from the data I have seen we continue to contribute to morbidity and mortality by intubating people in the pre-hospital environment. All this argument about aspiration and golden standard airway protection really does not seem to pan out when looking at the evidence. As I have stated in the past, EMS will have to step up and prove that intubation does in fact improve outcomes when utilized by pre-hospital providers. A mountain of evidence now exists that does not support the said concept. We can continue to cry about Wong hating on EMS or actually present our own evidence. Of course, this would mean EMS providers would have to further their education and take an active role in research. Tniuqs, I can understand your point; however, I have yet to see many EMS providers take any steps to improve this situation. In addition, I am basing my stance on EMS in the United States. I cannot comment about morbidity, mortality, and outcomes in services outside of the United States. Take care, chbare.

This in no way excuses the EMT's; however, I understand there is tension between EMS and the police over the crime scene. I remember a past news clip regarding the police complaining about disturbing the crime scene. Possible pressure from the officers on this call? However, what is wrong with people. You have to actually perform an assessment, yes? You know, assess for breathing, pulse, listen to the heart and lungs, look at the pupils, and obtain an ECG tracing in a few different leads. Just a thought. Take care, chbare. EDIT: I think this article was covered on an earlier newsbot post?

More evidence to throw on the already impressive pile of evidence that does not support EMS intubation. While others may have a point regarding ETCO2 use during intubation, this is only one part of the issue. Complications during intubation such as arrhythmia development, desaturation, and hemodynamic changes may go unreported or unrecognized. I will try to find a study where paramedics were asked how they felt the intubation went, and most answered it went fine without any known problems. When in fact, their equipment had continuously monitored and transmitted the date obtained during the said intubation. Unfortunately, the number of unrecognized problems during many of the intubation procedures were numerous. What good is having ETCO2 to verify your tube when you caused your head injury patient to desaturate or drop his/her MAP during the procedure? IMHO, the take home lesson of all this data is the following: The ball is now in our court. We will have to prove that we can safely intubate patients, and prove that what we do benefits patient outcome. We need to quit looking at this as something personal and we need to quit saying, "In my system..." The data is against us. If your system is different, you need to get off your duff and push for studies that back up what is coming out of your mouth. If we cannot provide large amounts of peer reviewed data to counter the current trend, then I can see the ETT becoming less popular. This data does not include looking at the ER's and saying , "Oh yeah, well the ER doc messes up, so there." We cannot justify our bad behavior by looking at other peoples bad behavior. This is our problem and we need to prove we have the solutions. Nothing personal guys, just my thoughts as they relate to the data. Take care, chbare.

Hehe, the nasty Caroline book. It was a dissapointment, and very polarizing. On one end, I loved the fact that it had a pathophysiology chapter, then total dissapointment with other chapters such as the cardiac section. As a side note, I really am fairly dull when compared to other tools in the shed. However, my Googlefu technique is so strong, it creates the illusion of intelligence. Take care, chbare.

Unfortunately, paramedic text books like to oversimplify conditions and simply give a "textbook" definition. However, anybody who appears rather ill with a petechial rash should have meningitis as a differential. This is why doctors have residencies and fellowships. It takes years to learn the difference between the textbook and reality. Ebola and all these other conditions may be considerations(Ebola & malaria are not associated with Fiji however.); however, do not let the zebra distract you from looking at the horse as well. Take care, chbare.

Let's not let this one die, more people need to see this scenario. A very important lesson is presented with this scenario. Let's be honest guys. the reality is we bombed this scenario initially. (my self included) Most of us went for malaria, dengue, or another illness. However, I think we missed an obvious meningitis: acutely ill with a charateristic rash. The history led me to suspect one problem, while de-emphasizing the pragmatic answer and deadly problem. For shame chbare, for you could have delayed treatment with your bias and tunnel vision. A great teaching point here. Point well taken. Take care, chbare.

A note about hospital ignorance. I have been watching the permissive hypotension thread, and would like to comment about that concept and how it relates to the topic at hand. Part of the new resuscitation methodology is a concept known as damage control resuscitation. Damage control essentially consists of two parts. 1) Blood products 2) Surgery. Part of the surgical aspect involves taking the patient to OR and performing damage control surgery. In essence, open and achieve rapid hemostasis. Following hemostasis, the patient is "stabilized" over several hours, then brought back to the OR for revision type surgery. In an ideal world, the only interaction EMS would have with the ER staff would be a friendly wave of the hand on the way to the OR. Since damage control seems to be effective and working well in the Gulf, where does MAST come into the equation. It does not really have a place. How are we to expedite delivery of a patient to OR with MAST pants applied? If anything, MAST use delays this process. Unfortunately, we need to look at the big picture. Gone are the days of applying the MAST and giving a high five to your partner for delivering a patient with a pressure to the ER. We need to look at the big picture, specifically at how our interventions effect the patient outcome. Not simply delivering a patient with a good blood pressure to the receiving facility. If we can provide good evidence that MAST use is a good modality when considering the big picture, then it may have a use. Currently, I am not convinced. Take care, chbare.

Unfortunately, I am not sure comparing EMS to the ER is a valid concept. EMS is a rather homogenous environment when considering the medical aspects of care. The ER is part of a much larger animal. Therefore, you have different providers bringing different skill sets to the patient. The hospital is more of a bigger picture scenario where you have multiple concepts that need to be completed. These tasks if you will cannot be completed by one provider, therefore we have nurses to coordinate and manage the overall nursing care, while allied health providers bring a specialty skill set and diagnostic advantage to the team, and finally, you have the physician looking at the overall picture and steering the boat toward the proper general direction if you will. This is simply not the case in EMS where you have a very specific pathway to follow so to speak. Obviously, this is changing with the proliferation of critical care transport, remote medical care, and other methodologies. Take care, chbare.

1) Looks like a petechial rash 2) Most obvious concern is coagulopathy 3) Supportive care, isotonic volume expansion, detailed history 4) Obtain vascular access and provide an initial fluid bolus, obtain a temperature, BGL and XII lead. Assessment questions: -Lung sounds -Abdomen -Focused Neuro Exam -Place Foley and monitor urine if possible -Head to toe exam looking for gross abnormalities Taking any medication? Any Allergies? Any medical history? Any surgical history? Anyone else ill? Travel to any other areas? Vaccination history? Any meds while in Fiji? Considerations -Malaria is a consideration; however, it is not typically associated with Fuji -Dengue Fever--->Potential progression to Dengue Shock Syndrome -Other rickettsial infections Treatment -Monitoring -Supportive Care -Contact medical control after comprehensive assessment and history -Limited definitive work up and treatment modalities in the pre-hospital environment Initial Hospital Work up -CBC with differential -Chem panel with LFT's -Coags (PT, PTT, INR, FSP) -Myoglobin -UA -Stool Guiac -Blood Cultures -Chest X-Ray -Consider CT for any neurological deficits -ABG & serum lactate Treatment -Supportive care -Analgesia and fever control -Consider antibiotics with an unclear picture (doxycycline) -Treat underlying coagulopathies and electrolyte abnormalities -Consider central line for ongoing resuscitation and monitoring of fluid status (CVP) -Monitor I&O and labs -Infectious disease consult Take care, chbare.

Any number of pathologies can cause muscle spasms. This person is elderly, diabetic, and most likely had multiple medical problems and takes multiple medications. Therefore, your differential must take many other pathologies into consideration. Do not focus on an elevated blood sugar, as you have multiple concepts to consider. Unfortunately, a pre-hospital work up is unlikely to reveal the cause of her signs and symptoms. If you can obtain patient follow up, you can turn this into a learning experience. Edit: A side note regarding the blood sugar. DKA has been diagnosed in people with blood sugars in the 200's. Do not use the blood sugar as the endpoint for your clinical decision making. Take care, chbare.

Actually, these courses are fairly standard pre-requisites for nursing and allied health programs in the United States. Some community colleges that offer paramedic, nursing, and other allied health programs require the same pre-requisite courses. This can come as a shock to nursing students who expect a two year program, only to find that the core program is two years long; however, they end up spending an additional year finishing pre-requisites. Just over a decade ago I had to take the following pre-requisite courses: -Biology I: 3 credits with 1 credit lab (was able to CLEP) -Human A&P I: 3 credits with 1 credit lab -Human A&P II: 3 credits with 1 credit lab -Introductory Algebra: 3 credits -Problem solving: 3 credits (A hybrid statistics and algebra course) -General Psychology: 3 credits -Microbiology: 3 credits with 1 credit lab -English compesition: 3 credits -English literature: 3 credits Co-requisite courses -US and state government: 3 credits -Nutrition: 3 credits -Wellness: 2 credits with 1 credit lab I cannot see how Dustdevil's recommendations would be considered unreasonable. The level of paramedic responsibility and clinical decision making really does require a solid foundation of pre-requisite courses that are at least comparable to nurses and other allied health health providers. As far as ECG and pharmacology books; you are better off taking courses in anatomy and physiology prior to thinking about ECG interpretation and pharmacology. You need to have at least a rudimentary understanding of cell physiology, general anatomy, and histology to really understand concepts such as three dimensional receptor agonists, metabolites, and the current of injury. Take care, chbare.

Take care, chbare.

Not trying to pick on you; however, what is your rationale for taking this stance? Take care, chbare.

MAST pants were initially known as "military" anti-shock trousers. The MAST concept dates back as far as the early 1900's; however, MAST pants were introduced and used as we know them during the Vietnam conflict. Hence the term "military." Take care, chbare.

Some documentation is not much to go on when making decisions about your clinical practice.. Here is a link to a recent article that summarizes allot of the data and literature about MAST pants. http://www.pubmedcentral.nih.gov/articlere...i?artid=2700619 Take care, chbare.

I still see ground based EMS providers apply MAST pants primarily to stabilize suspected orthopedic trauma. In recent years, MAST pants have fallen out of favor. A review of the literature is all over the place. Benefits and pitfalls of MAST pants use are also all over the place. However, with the concepts of "permissive hypotension" and "damage control" resuscitation & surgery coming out of the middle East, I would have to hypothesize that the concepts in support of applying MAST pants go against current evidence based medicine. Take care, chbare.

I am not a huge fan of A-Fib rate control or conversion in the field if it can be avoided. With this guy's history, it is difficult to know exactly when the A-Fib started. Has he been in A-Fib for a while and suddenly threw a small PE, or is this a true new onset A-Fib? If possible, I would rather have somebody above my pay grade make that determination. With the exception of the tachypnea, this patient is not in extreme distress. Therefore, I would not go with an aggressive treatment plan for a 20 minute trip to the hospital. Pain control and judicious fluid therapy sounds like a good option. We can monitor vital signs and obtain a blood glucose along with serial XII leads. As far as giving amiodarone to this guy: Amiodarone is well known to have significant pro-arrhythmic effects and has multiple medication interactions along with complex actions and pharmacokinetics. Therefore, the risks must be weighed against the benefits. In this case, I would not go down this path with the current information available. Again, I will defer the decision to administer this agent to somebody above my pay grade. Take care, chbare.

The typical consequences are comparable to infiltration of isotonic fluids. Local swelling and irritation are common findings. IV contrast media is not typically or particularly associated with causing tissue necrosis. Just a point of contention for other posters. IV contrast is not dye. Contrast does not "dye" or stain tissue like the well known dye flouresine. Contrast media simply acts as contrast for some of our imaging studies to improve visibility of the target area studied. Nit picking perhaps; however, I like to set the record straight on this one. Take care, chbare.

In addition, some states and employers may not recognize non accredited education. Take care, chbare.

Also consider the fact that poor initial airway management need not occur for a person to develop aspiration complications. Micro-aspiration, VAP, and other problems are encountered with intubated patients. The "ETT is a secure airway" concept really is incorrect. Also consider non-intubated patients who develop aspiration complications related to a disease process or injury. Take care, chbare.