chbare

I find that "gut instinct" really is not so much a magic flash of intuition as identifying subtle findings that point to a possible problem. Even in this case, you were able to identify ominous findings; however, you were not quite able to interpret meaning, other than to realize something is really wrong. Good job. Glad to hear the medic set things right. We all have our days; however, he/she too time out to apologize and set things straight. Now, off to nursing school with ya! Take care, chbare.

I cannot see how giving every EMT a gun will prevent deaths and violence. :? I can see more EMT's getting killed by their own sidearm and people getting shot that did not need to be shot. Take care, chbare.

What sort of problems? Or, are we going back to a prior point? It sounds like a paralytic was not utilized, and this is another case of the ever so popular PAI? If that is the case, I am not surprised problems were encountered. Take care, chbare.

As stated, the glide scope is a great tool and very effective. However, the technique for using the glide scope is quite different from traditional laryngoscopy. Somebody using the glide scope should have a good understand of how to properly use the device and have spent time working with the device under the guidance of an experienced operator. Intubating in theatre under the watchful eye of an anesthesia provider who is well versed is using the glide scope for example. I would hate for somebody to blow off a device or technique because they saw another person use the said device/technique without success. Actually, you can use the bougie in many different ways. I have seen people use it like a stylette/stylet. In addition, I have used it to exchange a couple of tubes where either the cuff was not functioning or the tube was too small for the patient. I have also seen people opt to use the bougie if their airway assessment indicated potential difficulty. Then, they ended up having a high POGO and simply inserted into the glottis, then placed an ETT. Obviously, people can also use the bougie with poorly visualized glottic anatomic structures. Then, note the presence of tracheal clicking and stoppage for confirmation. You see, many options are available and people have the ability to use several techniques. Personally, I am a big fan of the bougie. I would not call it stupid, I simply like having additional options. The bottom line is having enough experience and understanding to properly use the said tools and techniques. Take care, chbare.

Hehe, ever watch a cardiac surgery? Pretty strange watching somebody receive 1 mg or more of fentanyl for induction. Take care, chbare.

Some providers may use 06. mg/kg; however, to give a double dose of etomidate to compensate for the lack of sux is a dangerous precedent to set and defeats the purpose of RSI. Regardless of the 0.3 mg/kg or 0.6 mg/kg dose, etomidate is not a replacement for paralysis. Take care, chbare.

Wow, why do that? You are not going to have the same action as sux by doubling your etomidate dose. From what I understand, a single "normal" dose of etomidate has been shown to cause adrenal suppression. At one time, etomidate was used for ongoing sedation in ICU's; however, the practice was stopped and now etomidate is not to be given in follow up doses or for ongoing sedation. I do not think anybody can argue the fact that adrenal suppression can occur with etomidate. However, I am not ready to convert to some other agent. I am curious to see what other studies find; however, when compared to the alternatives, I still like the advantages etomidate brings to the table. In addition, with the push to "stress dose" people with steroids, I will be curious to see how the whole etomidate concept pans out. I have also been in at least two discussions about etomidate on flightweb. Take care, chbare.

Wow, I look back on my high school days and as I recall, I only had a few things on my mind. Obviously, the guessing game should be a no brainer on this one. I guess the question I asked my self is, "what would I have done if I had camera phones and such as a teenager." Obviously, I know the answer. :oops: Seems rather strange that we have all of this drama over foolish teenager activities. Obviously, I do not condone such activities; however, criminal charges and a "sex offender" record that will follow these people for the remainder of their life? Take care, chbare.

Happy Birthday! Take care, chbare.

The following is from the AHA "Circulation" journal prior to implementing the 2005 ECC changes. Off topic; however, good information for those who what to know some of the rationale behind AHA changes. "The ECC Guidelines 200033 recommended the use of a so-called "stacked" sequence of up to 3 shocks, without interposed chest compressions, for the treatment of VF/pulseless VT. Although no studies in humans or animals specifically compared the 1-shock defibrillation strategy with the 3-stacked-shock sequence, other evidence created the tipping point for a change from a 3-shock sequence to 1 shock followed immediately by CPR. The 3-shock recommendation was based on the low first-shock efficacy of monophasic damped sinusoidal waveforms and efforts to decrease transthoracic impedance with delivery of shocks in rapid succession. Modern biphasic defibrillators have a high first-shock efficacy (defined as termination of VF for at least 5 seconds after the shock), averaging more than 90%,34,35 so that VF is likely to be eliminated with 1 shock. If 1 shock fails to eliminate VF, the VF may be of low amplitude and the incremental benefit of another shock is low. In such patients, immediate resumption of CPR, particularly effective chest compressions, is likely to confer a greater value than an immediate second shock. After VF is terminated,36–38 most victims demonstrate a nonperfusing rhythm (pulseless electrical activity or asystole) for several minutes; the appropriate treatment for such rhythms is immediate CPR. Yet in 2005 the rhythm analysis for a 3-shock sequence performed by commercially available AEDs resulted in delays of 29 to 37 seconds or more between delivery of the first shock and the beginning of the first post-shock compression.38,39 This prolonged interruption in chest compressions cannot be justified for analysis of a rhythm that is unlikely to require a shock. Experts recommend that rescuers resume CPR, beginning with chest compressions, immediately after attempted defibrillation. Rescuers should not interrupt chest compressions to check circulation (eg, evaluate rhythm or pulse) until after about 5 cycles or approximately 2 minutes of CPR. In specific settings (eg, in-hospital units with continuous monitoring in place), this sequence may be modified at the physician’s discretion. The recommendation for a 1-shock strategy creates a new challenge: to define the optimal energy for the initial shock. The consensus is that it is reasonable to use 150 J to 200 J for the initial shock with a biphasic truncated exponential waveform or 120 J with a rectilinear biphasic waveform. In recognition that many EMS systems may still be using monophasic defibrillators, the consensus recommendation for initial and subsequent monophasic waveform doses is 360 J. The goal of this recommendation is to simplify attempted defibrillation. For children, the consensus recommendation is an initial dose of 2 J/kg (monophasic or biphasic); for second and subsequent biphasic shocks, it is advisable to use the same or higher energy (2 to 4 J/kg). Manufacturers of defibrillators should ensure that each of their products clearly displays the range of energy levels at which each specific defibrillator waveform was shown to be effective at terminating VF. Healthcare providers should be aware of the range of energy levels of the specific device they are authorized to operate." (Circulation. 2005;112:IV-206 – IV-211.) © 2005 American Heart Association, Inc. Take care, chbare.

It is a reference to the newer AHA guidelines that recommend one shock followed by two minutes of CPR. I suspect the original post was referencing situations back when "stacked shocks" were common practice. Take care, chbare.

Shoot, many of the medics I work with have degrees. Most of the South African medics I work with have either three or four years of education. The Australian ACP's all have around three or more years of education. Not a big surprise that companies are requiring degrees for medics. Even medics going into conflict areas. Take care, chbare.

Seems like pretty good training. Take care, chbare.

Actually, many exist. Reciprocal changes in the V leads are not uncommon in the presence of inferior wall MI. ST segment changes in the V leads should also increase your index of suspicion for posterior wall infract as well. In fact, some people talk about doing a mirror test to ID posterior wall infarct with ST depression in the V leads. However, I prefer to simply look at the posterior leads. Take care, chbare.

As a nurse, it sure is fun to blame to woes of western society on physicians; however, I could be off on my assessment. I found a case review from 2003 from New England Journal of Medicine: A 47-year-old man with no history of cardiac disease presented to a hospital, reporting severe substernal chest pressure associated with bilateral arm weakness. A standard 12-lead electrocardiogram (Panel A) showed marked ST-segment elevation in leads V1, V2, and V3 and slight ST-segment elevation in leads II, III, and aVF. The patient was treated with fibrinolytic therapy and transferred to another hospital for catheterization. Angiography showed severe proximal stenosis of a small, nondominant right coronary artery and no clinically significant disease in the left coronary artery. Contrast-enhanced magnetic resonance imaging 48 hours after presentation (Panel showed delayed hyperenhancement of the right ventricular (RV) free wall (arrowheads) and sparing of the left ventricle (LV) and the right ventricular apex — observations consistent with the presence of isolated right ventricular infarction. Isolated right ventricular infarction is uncommon and accounts for less than 3 percent of cases of myocardial infarction with acute ST-segment elevation. The electrocardiographic changes may be misinterpreted as signs of infarction of the anterior wall because of the ST-segment elevation in leads V1 and V2. Our patient did not have the typical hemodynamic abnormalities associated with severe right ventricular infarction, probably because of isolated infarction of the right ventricular free wall with sparing of the apex. The patient was discharged in good condition. Finn and Antman 349 (17): 1636, Figure 1 October 23, 2003 Again, we have the changes in our V leads and even subtle changes in our inferior leads. However, we are not talking about the relationship between inferior wall MI and RVI. Again, these changes appear to be associated with isolated RVI. Take care, chbare.

Absolutely agree. I think some of these concepts have been confused and taken out of context. While, elevation of your V leads can occur with isolated RVI, like you, I still think V4R is still one of the standards when attempting to look for RVI using XII lead evidence. I suspect the RVI problem associated with PCI is related to inadvertent occlusion of vessels down stream during the procedure. This may also be related to right versus left coronary artery dominance and the said procedure. Take care, chbare.

Exactly, this is associated with isolated RVI; however, isolated RVI is in fact quite rare. In addition, all of this "left" and "40%" stuff seems to be taken out of context. Depending on your sources, around 1/3-1/2 of all patients experiencing inferior wall MI will also have RVI. This is what I gather from the article posted earlier as well. It only mentions 40% association with "left inferior wall MI." However, this concept seems to be taken out of context as many people associate inferior wall MI with the inferior wall of the left ventricle. So, we are in fact simply using little different terminology to describe the same problem. Inferior wall MI. The first article is a general overview of RVI. While anomalies and additional research exists, the V4R is still highly sensitive and specific to RVI identification. The second article focuses on the different characteristics of RVI. I would ask people to focus on the fourth paragraph under the discussion. http://emedicine.medscape.com/article/157961-diagnosis http://www.invasivecardiology.com/article/2975 Take care, chbare.

Uhhh, when we talk about inferior wall MI, we are in fact talking about the inferior wall of the left ventricle. Not exactly new knowledge brother. Assuming "normal" coronary artery anatomy: Right Coronary artery supplies the SA node, AV node, right ventricle, LEFT VENTRICULAR POSTERIOR WALL, and LEFT VENTRICULAR INFERIOR WALL. Obviously, the nodal arteries and the PDA among others branch off of the RCA. However, the whole "left" concept you keep bringing up is nothing new. Take care, chbare.

Point being, we are talking about V4 versus V4R . Big difference between these two leads. In addition, your article focuses on V4R and it's importance associated with the identification of RVI. Take care, chbare.

Yeah, it is also in the Brady Critical Care Paramedic textbook. However, I strongly caution against learning and utilizing catch all formulas. This sets you up for complacency and medication errors. Especially, if you happen to mix a "non standard" concentration. Take care, chbare.

Simply take your V leads and place them around the right side of the chest. http://ccn.aacnjournals.org/cgi/content/full/25/2/52/F3 Take care, chbare.

We are talking about a patient so intoxicated that nasal intubation was performed to protect the airway? The patient was vomiting as well and thus at high risk for aspiration prior to and during the intubation. Also, an ETT in the trachea does not totally prevent aspiration. In addition, saturating well may not mean doing well. Patient could be retaining Co2 like a champ. Finally, you can actually alter the dynamics of oxygen usage with high levels of ethanol. It can actually produce a type of hypoxia known as histotoxic hypoxia. I would have a hard time assuming all is going well with this patient with the information provided. Especially well enough to allow the patient to breath through the ETT with a NRB mask placed over the tube. If the patient is in fact doing so well, perhaps we should go ahead and wean the patient from the tube on the way to the hospital? I bet Betty would be impressed with our mad RT skillz. Take care, chbare.

Forgot the good old syringe driver. Take care, chbare.

I am not quite sure what VC is? I will assume vena cava and you can correct me. The pressure in your vena cava is for all practical purposes your central venous pressure (CVP). Pulmonary venous pressure is a bit tricky. First, we do not directly measure pulmonary venous pressures. I think some research has been performed measuring these pressures; however, this would involve threading a catheter through an artery into the aorta, through the aortic valve, into the left ventricle, through the mitral valve, into the left atrium, and finally into one of the pulmonary veins. Obviously, this would place the patient at significant risk, especially since we are threading a catheter into the left ventricle. However, we can indirectly look at pulmonary venous pressure. When we place a pulmonary arterial catheter, we can perform a procedure known as wedging. Essentially, we inflate a tiny balloon in the pulmonary artery and wedge it. What this does is block off input from the right ventricle. So, all we are looking at in the pulmonary artery, veins, left atrium, and left ventricle. We can make assumptions based on data gained from the PCWP or pulmonary capillary wedge pressure. In a normal person without lung, valve, or heart problems, the pressure in the pulmonary venous system should roughly approximate mean left atrial pressure or wedge pressure. Obviously, we are dealing with gradients, so variations will exist. Here is an abstract on dog research that may help: http://www.ncbi.nlm.nih.gov/pubmed/12112902 Here is a link on PCWP: http://www.cvphysiology.com/Heart%20Failure/HF008.htm Another helpful site is the pulmonary artery catheter education project Take care, chbare.

Thank you for the scenario. Take care, chbare.