croaker260

Depending on the time from motrin to onset of s/s, perhaps an anaphylactoid reaction? NSAIDS (motrin and ASA particularly) are associated with certain ideopathic and anaphylactoid reactions as "triggers" required for onset, particularly in exercise induced anaphylaxis. Often S/S will not become readily apparent as they are masked by the hypotension. Once the hypotension is addressed, the patient seems to "erupt" with erythemia, etc. .

Agreed, but it is so deeply ingrained that honestly I had never even considered how it sounded until you mentioned it, and you know me I am usually a stickler for those type of things. Its as ingrained as using the term "code" for cardiac arrest.

This was going to be my post Bushy...Dam You! OP: Recommend reading Grossmans "On Combat" for more on this and its impact on People like us.

"Breathing Treatment" is just common vernacular over here, because its understood by the lay public easier than "nebulizer" or more specific terms. How it became a standard part of the EMS lexicon is rather inane, but it has none the less.

Joplin MO

The short version of a long and tedious comedy of errors story...After said 14 hour flight (should have been about 7) which ended up at midnight in the destination city. This was after an allegedly simple respiratory patient not tolerating altitude very well. Additionally, our "destination"..allegedly rehab hospital was in actuality a hole in the wall roach infested nursing home. So , after fighting with the doc and getting the patient actually admitted to a hospital.......the only place to eat was a restaurant right next to the strip club...apparently the only two places open after midnight that we could find. And the dancers got off duty right as we arrived. They flocked (waddled) to the same eating establishment that me and my partner were visiting. Well.... exhaustion does funny things to the brain, and I already have some difficulty keeping my mouth shut... so after some poorly thought out comments ...its always funny to see two full grown men in flight suits getting yelled at by a glittered covered stripper who outweighs them. This is in between getting hit on by the waiter (who was wearing makeup). On a good note, the food was decent. And we didnt end up in jail.

I think you misunderstood my post entirely. Utterly. Completely. Totally. My comment was on the OP's use of the term "asymptomatic" , where i believe "symptomatic at their baseline" a better descriptor of some of our patients (not necessarily the OP's scenario, but pertinent tot he overall discussion). In fact I was saying...if you re-read my post...that the patient was not "asymptomatic". Since your comment that I was saying this patient was asymptomatic is based on a false assumption, I will leave your other comments regarding a silent chest, not to mention the physiology of end expiatory wheezes alone. What I posted was a comment on somatics, the perception of patient severity, some basic philosophy of medicine, and most of all a basic understanding that people live with chronic disease process that are indeed symptomatic and impact their daily lives, and their daily lives had adapted to that reality... I was also saying that it is perfectly appropriate to help a patient (after thourough subjective and objective assessment) continue to control their own disease process through continuing their own regimen of broncheo-dilators on their own schedule while they are in your care, even if they dont quiet meet the criteria of urgent/emergent/in distress. I will give you points for the cardiac asthma train of thought. It is a reasonable differential Dx, but still not mutually exclusive of my comments either. This is where the subjective (including a thorough history) and objective assessment helps you determine the best course of action. After all, 70% of your working field Dx is gleaned from talking to (and listening to) the patient. And, for what its worth...I have a fair amount of experience with patients over extended periods of time including loooong CCT transfers (fixed wing and ground) , as well as in hospital experience as well. I am well aware of the physiology of "cardiac asthma" as well as non-cardiogenic pulmonary edema in all of its various flavors, not to mention various breeds of pneumonia (fungal, aspiration, community acquired, institutionally acquired, VAP, viral, and my personal favorite to read about...parasitic) . That said, like everyone on here, I can always learn more. To end my rant on a positive note: Off the top of my head the longest respiratory patient I have had to deal with was 14 hours on fixed wing between Seattle and Joplin MO. Clinically a very interesting flight, but not as interesting as the bovine-hormone saturated exotic dancers I saw afterward...but that is another story. namaste' After careful review, and seeing that my original post was quite brief, I apologize if I came across harsh. Sometimes the thoughts we are trying to convey come across our brain but seldom make it past the keyboard.

Pot calling kettle black.... <<Deep Bow >>

To answer the original question (though I am a NERD myself...) I will illustrate a real word example why listening to the heart is useful. Many years ago I rolled out on a very simple sounding flu lie s/s patient. Sweet Old School Country lady, ambulatory, positive Samsonite sign. Her only complaint was she felt dehydrated and run down, and the last time she had this she had to be admitted with the flu. She wanted to "get ahead of this damn thing". BTW, this was right in the middle of "flu season" in the south. She ambulated (at her insistence) to the ambuilance and only with some southern charm did I get her on the cot and allow a set of vitals. She was a touch SOB from the walk but that really wasn't surprising. Vitals were text book perfect with a HR at the radius and on the SPO2 of 98-100, and her SPO2 was in the mid 90's on RA. Her skin turgor was poor but not bad (typical old people skin), she was rather perky, and she looked, tasted and smelled like a typical (very stable) elderly dehydration patient. As a part of a routine physical exam I listened to her lungs and noticed something odd. Instead of the thump thump at 100 beats a minute, I hjeart a very rapid tap-tap-tap-tap-tap-tap-tap-tap-tap-tap-tap-tap-tap at about 200! Sure enough, hooked up the monitor and there she was in a little SVT at about 200/minute. Given a number of factors I may have never had put the monitor on had I not heard the rate. 6 of adenocard later she felt 100% better and wanted me to take her back home! Anyway, THAT is why I always listen to lung sounds and heart sounds when ever I can remember it. THAT is why listening for arrhythmias is useful. You probably wont be able to tell WHAT the rhythm is, but it may keep you from making a STUPID mistake. Imagine the bad karma to bring in that patient BLS/ILS and the look on your face when they do the routine 12 lead 90% of patients seem to get today. Hope my lil war story is useful.

Most everyone has good points, I will agree with most of them and add one more consideration I didn't see above (though I may have missed it). Some patients are on regular nebulizer treatments several times a day. If the patient is otherwise asymptomatic (if he has wheezes, is he really asymptomatic, or simply at his symptomatic at his baseline? ) , but due for his treatment then I may administer one to keep his chronic condition from being exacerbated...depending on transport time, etc.

I'm in the same line as others. In fact, in our orientation /academy during day one..its discussed that you can accept discounts but not ask for them. Its part of the customer service/professionalism lecture I believe. I'm just happy when they rewarm my meals when we get back from a call...those are the places I will frequent more often. ALso, any place that gives me a discount, I tend to add that same $$ to my waitress tip as a matter of habit. Afterall, they work even harder than we do.

Just look at what wake county is doing with their advanced practice paramedic. We are in the works for something very similar called a community paramedic here. Eventually these will HAVE to be a BS or higher degree. Current paramedic education doesnt cover it, and to be comprehensive and respected it will have to be taught at the university level.

Good Question. The answer is "Adult Diapers" (AKA " It DEPENDS" Get it...Depends? I crack myself up...) Anyway... It varies by state to state law, but generally every state has SOME version of law that requires mandatory reporting in the following cases: Animal Bites New Onset STD's (applies to all healthcare providers, but this is seldom if ever a concern for EMS) New Onset of certain highly infectious Diseases, i.e. Tuberculosis, meningitis, anthrax. Gunshot wounds of any type Puncture wounds and blunt force trauma believed to have occured in an assault. Injuries believed to have been encountered during a criminal activity ANY injuries believed to have occurred in domestic violence, or any injuries or illness believed to be the result of abuse (physical/sexual/emotional) or neglect (physical or medical) to a vulnerable population group (i.e. the elderly, disabled, or children) Now a comment on mandatory reporting: Each state has different definitions of who and what is a mandatory reporter (EMS is usually included in some form or another) as well as who you report to. Depending on the situation you would report (or in some states causing to be reported is acceptable ...in others it is not) to either law enforcement (in Idaho defined as a "Peace Officer" - specific legal definition outlined in code) or the health/social services Department (s) (child and elderly protection falls under this in Idaho), or BOTH. Most laws require reporting within a certain period, typically " as soon as practical" with in 24 to 72 hours though the actual wording may vary by state. So, if the patient is already being transport, an EMT may decide to "report" later (as in when the patient isn’t around and will get pissed off) when it is safer to do so if he is already getting transported. This does not cover situations where EMS will request law enforcement for safety reasons. For example, if a patient is intixicated, drunk, agitated, or otherwise goofy and it makes the EMS crew uncomfortable, Law Enforcemnt may be called. I hope this helps. All the time. Sometimes the initial cal for dispatch will be some a benign complaint (i.e. chest pain) when it is drug related just to avoid a law enforcement dispatch. Usually a seasoned medic has a pretty good BS detector though, and we can usually tell when a story doesnt match the injury pattern. That said, patients can be pretty creative in their BS.

Common out here , pretty much the same crowd here that was in the spice craze last year or so. There is no specific antidote for bath Salts like narcan for oopioids or drug specific treatments like Bicarb for TCA's. That said, supportive care, ABC's and benzos for sedation are the mainstays of treatment. Also prevention of the "horrible H's of hyperdynamics" (yes, I just made that up....)...Hypoxia, Hyperthermia, and H- Ions (acidosis through hypoventilation and increased muscle activity) will keep you out of trouble, especially if you do restrain them (see numerous threads on excited delirium, positional asphyxia and restraint related deaths for more insight). Hope this helps.

I would prefere a right sided verticle holster as well. If your buddy will make one ofr you, ask him what he would charge..I may be interested as well.

I have actually had the pleasure of meeting Thom Dick (not his real name BTW) and hearing his People Care Presentation first hand. I have met many sage and wise medics. He is a sage and wise man, who just happens to be a medic. One of the salient points of his presentation is this: The 4/2 rule. 4 --- 2 What we do "For" a patient is always more important than what we do "to" them. You know, there are medics who get "Customer Service" intuitively..they may not call it customer service, but they understand that only 10% of our calls are critical, and only 40% even require ALS...but all of our patients/customers require interpersonal communication...the major part of "customer service. The medics who dont grasp this intuitively seem to veiew customer service as a chore, like a false face you put on when you work a food service job or retail. And I understand why...afterall that is the "face" of customer service in todays society. But that is not customeer service....customer service is follow through and follow up, it is honesty and integrety, it is going the extra mile even when it means cleaning up a 3 day incontinent patient, and its making sure the pets are safe before you leave. Remember , if we do these things we are not just being nice, it is a tool to build better patient raport and thus provide better patient care...just like any of the medications, dagnositics, or other tools on our rig.... As Thom dick says...its not Patient care...its People care. Customer service is an ill fitting name with a negative perception.....but one that is easily recongizable by admin so it is the name we get saddled with. I prefere Thom Dicks name better. Does that make sense?

Lets not forget DC fire and Detroit Fire as examples of EMS done horribly wrong by the Fire Service.

Yu T, Weil MH, Tang W, et al. Adverse outcomes of interrupted precordial compression during automated defibrillation. Circulation 2002;106:368-72. and Eftestol T, Sunde K, Steen PA. Effects of interrupting precordial compressions on the calculated probability of defibrillation success during out-of-hospital cardiac arrest. Circulation 2002;105: 2270-3. Also, I just read an article discussion on a newly released study that showed similar results on survival to discharge.

In the US I believe it used to be an FDA requirement that any defib will revert to unsynchronized mode immediatly after syn cardioversion for the very situation discussed above. I could be wrong though....

Actually there is decent research (and more every year) that the length of inturuption and ROSC have an asscoaition that is measured in seconds. There is a significant difference in time to Defib of 5, 10, and 15 seconds and resultant ROSC....... If I understand your statement correctly I think that can be extrapolated over to any inturruption and its effect on coronary perfusion/ROSC.

Horizontal, just on the side and not the back, with the handel facing foward so for me its on the left side. The back is really uncomfortable for me for some reason . There is a custom leather shop hear in town that made the CCW holster for my .40 VERTEC beretta...(yes I AM bragging...LOL) but they are not cheap..so I havent decided if I want to fork down close to a hundred dollars for a custom holster for the BIG SHEARS...no matter how nice they are. I may still ...but it will be something useful and well thought out..probably cary a mini mag as well and the small field guide as well. thats about the only thing I need besides gloves. ...though still not decided. It may be too wankersish....but I digress. If I think something up, want me to PM you with the result? ...they do on line orders I think as well.

Here is a slide share presentation I put together on EMS customer service I used to give in our training academy. It includes soem stuff I had gathered from other programs and services. The formatting gets a little wonkey in the slideshare viewer, but usually downloads fine if you want it. http://www.slideshare.net/croaker260/27-acp-customer-service

1- The King, Combitube, PTL, etc are all less than gentle/delicate insterion proceedures. Therefore even on the best days there is tissue swelling. On the worse days the MD forgets to deflate the cuff before pulling it. 2- Ive used both the King and before that the Combi during arrests...they seem to do well. I will admit that I have never hooked on up to a ventilator AND CPR both.... Food for thought...ETT with or without RSI is a perishable skill, that requires continous performance to maintain.... If the only time we ever intubate are RSI, the skill will perish. Not saying this is the main reason to ETT durrring arrest, but with the advent of CPAP we just dont tube as many people anymore. If we arnt careful, the best of us will become unskilled....Bad ETT success rates will be a self fulfilling prophecy.

I have had my pair of BIG SHEARS (bigshears.com)for about 5 years. I wear them on the side, the back seems to be uncomfortable to me when sitting itneh rig for longer than 5 minutes. On the side it seems to balance out the monster brick 700 mhz radios we wear. I love my bigshears...wouldnt ever give them up. Especially during winter up here with the heavy winter garb people wear down from the ski mountain. I am unaware of a truely comparable product. The one downside: The price. If you are the type that loses your sunglassess, keys, shears, and wallet within an hour of each other 3-5 times a week...I wouldnt waste the time or money because you wont keep them long enough to use them much. If you can keep ahold of your crap, then they are worth it.

Uhmm... While I am very pro-ETT, I have to say that if I place a blind airway, and its working, it is counter productive to replace it with an ETT "Just because" . In my experiance, everytime I or a doc has removed a blind airway to intubate...even when justifed, it has been a difficult tube and usually is a horrible mess. Moral: once a blind airway is placed, it stays in unless I have a specific reason to remove it.