chbare

Ok, look at the XII lead and identify leads with changes. Then, with mad Google skills, find out what vessel/s (assuming "normal" coronary artery anatomy) is/are involved and what area of the heart is effected. This may help you with clinical decision making. Yes, GTN is simply another name for NTG. I am the only American surrounded by Africans and Australians, so I have had to learn a little about the Queens English. GTN means Glyceryl trinitrate. Why are some hesitant to give GTN? What other problems may be associated with what we have already identified? Think about anatomy and physiology and structures possibly involved. In addition, look at the XII lead, are there any other disturbances of conduction. I have additional XII leads and a great rhythm strip; however, they will come after we initiate therapy. Let's say we do have the ability to give fibrinolytic therapy. This adds a new dimension to our clinical decision making. Let us discuss the possibility of giving it. Are we sure of the diagnosis at this point? Risks versus benefit? Indications and contraindications? What do you all think? After 250 Ml of NS the pressure increases to 90 systolic and you note clear lung sounds. You decide to give another 250 ML NS. Into the second bolus, the patient begins to report decreased pain. The current B/P is 102/66. Why do you think the pain improved? There is in fact a Role III Canadian ISAF hospital at Kandahar; however, you cannot use them, sorry. It is great that we have a few new faces to the scenarios. By all means, continue to discuss. Take care, chbare.

Onset was about 2 hours ago. Physical activity exacerbates the pain. Radiation into the left upper arm. Pain is 10/10. She describes the pain as a very "heavy pressure." Lung sounds are clear throughout. You initiate a 250 ml bolus of NS. Answer a few other questions asked earlier: Patient appears pale, warm, and slightly diaphoretic. Heart tones: S1 S2 & irregular. No history of any trauma. Family History: mother died of breast cancer, father died of a MI at age 55. Not sure on advanced directives: I assumed an otherwise healthy 41 year old female would be a full code. (never know I guess) Your initial XII lead: She is a little anxious, so there is artifact. Take care, chbare.

Hmmm...goats, outdid yourself on that one. Dwayne is lucky to have such a caring friend. Happy birthday old man! Take care, chbare.

Good, is the field secure and how will we get from the field to the clinic and back? You are able to arrange security at the field and an escort to and from the clinic. Good call on the bathroom, I always bring an extra urinal. Weak bladder and all. Upon arrival you note an anxious patient obviously experiencing some sort of distress. Take care, chbare.

Hmm, cannot say I ever remember using a glucometer that said "no" do not give dextrose. Learn something new every day. Take care, chbare.

http://www.youtube.com/watch?v=10tMyrFy_1g Take care, chbare.

Depends, what number do you consider normal. Some people have hypoglycemic symptoms/signs with "normal" sugars. However, I am not an advocate of blindly pushing medications as is the case with simply giving coma cocktails to every unconscious patient. I am not sure how you found the comment derogatory? Take care, chbare.

Agree with Doczilla on this, assessing pressures in both arms is a commonly encouraged assessment technique. Take care, chbare.

Before we get too far into patient contact, any other considerations regarding the situation? Think about the situation and the scene. The nurse is able to give you a little more history before you take off: No Known Allergies. No past surgical or medical history. No regular use of medications. Social History: Smoker 1PPD times 25 years. Discomfort started suddenly 2 hours ago. Complaints of mild nausea without vomiting, no dyspnea, and complaints of a couple of near syncopal episodes. The nurse has given the patient supplemental oxygen, 300 mg of ASA, and placed an IV medlock. Have you covered on the barf bag. I actually have terrible motion sickness. I generally pre-medicate with Antivert and use Dimenhydrinate for break through nausea. Off topic, but I had motion sickness so bad one time, I hyperventilated my self into carpal pedal spasms. Very hard to barf into the bag when you cannot even hold it. A mess to say the least. So, I always medicate if I roll on a fixed wing. Take care, chbare.

Good, we want to gather pre-mission information. The patient is a 41 year old female complaining of chest and back pressure along with near syncope. Vital signs include: 92/54, 50 and irregular, 22 unlabored, 98% on 2 lpm, 36.9 C, BGL-6.5 mmol/l, pain -10/10. The nurse is a bit stressed and unable to give you additional information. She only has an AED without monitoring abilities. No labs and no radiology. Your equipment is a typical EMS paramedic kit. Good monitor, meds, and the ability to RSI. Limited diagnostic capabilities. Anything else to consider prior to taking off? Think about how you will get to the clinic and what about landing at a small airstrip in Northern Afghanistan? Take care, chbare.

This is a scenario based on a medical evacuation I just completed. I would like to ask the "old farts" here to hold back a bit and let some of the novice members throw in their thoughts. This is a bit different from my typical "zebra" scenario; however, I think it is nice to see a patient through more than just the acute phases of their illness. In addition, I will throw in other factors that some of us in the the US may not consider on a daily basis. Here goes: You are the member of an international medical evacuation team working in Afghanistan. You are on call with a physician. The physician has family practice experience without any significant emergency, transport, or critical care exposure. You have been called to transfer a patient out of a small rural clinic in Northern Afghanistan to Wellcare hospital in Dubai UAE. The working diagnosis at the moment is chest pain. The clinic is small and manned by a single nurse with very limited equipment and diagnostic capabilities. You will be flying a King Air 200 into a small airfield about 8 kilometers from the clinic. In addition, you expect at least 40-50 knot head winds en-route to Dubai. After picking up the patient, you will have a 1.5 hour flight to Kandahar where you will land and refuel. After refuel, you can expect a four hour flight to Dubai. Total transport time including refuel is approximately, 6 hours. (Not including time spent packaging the patient and transport to and from the rural clinic.) Take it from here. Take care, chbare.

Strong work everybody. i am glad you liked the scenario. The patient this scenario is based upon received minor injuries; however, I thought it would be neat to discuss some of the considerations with electrical injuries. I cannot recommend any lab books at this time. The book I used in nursing school must be around 7 years old. Too bad labs are not emphasized in your program. With EMS taking a role in patient facility transfers, knowledge of lab findings and implications is in fact important knowledge. In addition, it is nice to look at a condition you see in the field and connect that with possible lab findings. Renal failure with ECG changes should raise your suspicion of a potassium imbalance for example. Take care, chbare.

Take care, chbare.

Hehe, I thought this was going to be a thread on some new alternative life style. Take care, chbare.

Also remember, CHF is usually caused by some other problem such as CAD. In addition, it is not uncommon for people to experience both left and right sided failure. Given enough time left sided failure can cause right sided failure. Other conditions that can cause heart failure include; chronic lung disease, heart valve problems, HTN, infection, and many other problems. I find CHF is rarely an isolated condition. Take care, chbare.

This is exactly how I view the situation. In reality, I know f*** all about performing a field C-section. I am not sure watching a couple in the OR counts. What good am I really going to do in this situation? Take care, chbare.

Food for thought. I have a good friend back in the states. I just talked to him a few days ago. He provided an intervention that he thought was in the patient's best interest. He had orders that were open to interpretation. He interpreted and acted. He just lost his license because of his decision. He has a wife and four children. One is a toddler. In addition, he has a fair amount of debt. I am not sure what will happen; however, it does not look good. I understand the people that need to do what they need to do to sleep at night. However, I know where my priorities lie. Medicine is how I make a living. It is how I take care of my family. It is what pays for the outstanding insurance that sent my wife to one of the best retinal surgeons who saved her vision. My priority lies with making sure my family is safe and secure. With that, I absolutely appreciate the fact that I will have to make a choice in the here and now of a situation. So, I am sitting back and looking at things without the perspective of actually experiencing such a situation. However, as it stands, sorry baby. I am not saying this is the "right," "correct," or even "moral" answer. It is simply my answer. Take care, chbare.

With the location, I would suspect damage to the peroneal nerve. Take care, chbare.

Agree, and look, I am a capitalist pig at heart. I am making a good wage, working a respectful job, and I am letting Uncle Sugar take his share of tax money. Cannot say I see a problem. Take care, chbare.

Well, dopamine is not exactly a medication we use for the patient in arrest regardless of rhythm. In addition, no solid evidence pointing to better outcomes with epinephrine use in arrest exists. Why go through all the trouble of setting up an epinephrine infusion when it's use really does not seem to effect outcomes in the first place? Take care, chbare.

I can "think" whatever I want about these people; however, it is my job to "show compassion" to patients regardless of what I may think. Regarding the sugar comment: This is what separates a protocol monkey from a true provider. Why is the sugar low? What is going on with this patient? What additional assessments must be completed? Are there other interventions that can help and perhaps opportunities to educate our patients about their conditions? Are adequate support systems and access to ongoing care in place after the patient leaves our service? Can we introduce a customized plan of care that can prevent this from occurring in the future? You see, we can fix the number; however, what about the actual cause of the low number? I hope somebody gets where I am going with this? Take care, chbare.

He was working at a power plant near high tension power lines when he fell and was found in arrest. Young guy, healthy, no known history. Take care, chbare.

What about all of the other findings? Take care, chbare.

Start at the beginning. Young guy falls at a construction site and is found in cardiac arrest. AED is attached and advises, "shock advised." Patient is shocked into a perfusing rhythm. (Not exactly characteristic of a "traumatic" arrest.) XII lead is performed and indicating massive MI. Pt also has "unstable" vital signs and runs of ventricular tachycardia. The only signs of "trauma" are obvious arm deformity and red marks on a hand and a foot. During his stay at the hospital he develops rhabdo, compartment syndrome of his extremities, and abdominal compartment syndrome. Assuming he is healthy otherwise and there is more to the story than a simple fall, what the heck is going on, what could be causing all of these problems? Take care, chbare.

Consider the event that caused this entire mess. Somebody mentioned the problem earlier. What underlying pathophysiology is at work here? Take care, chbare.