scubanurse

That's a very nice hotel with lots of food options very close and a short ride to DC on the red line... just know, North Bethesda is just the fancy name for Rockville... It's still a good bit away from downtown but not a bad METRO ride at all, and like I said close to some really good food and shopping.

That is awesome!!!! I forwarded that to my dad who used to work a lot with hospitals and EBM

I have had a few docs reduce without x-rays, but I'm a special case. Often the patient if they have dislocated multiple times can tell you if it feels the same or different than the times before. The times I've known it's been exactly the same pain/circumstance for dislocation the ER doc will usually just reduce it. But if it feels even slightly different, I tell them and insist on x-rays so that I can be sure my bone graft hasn't cracked.

Makes sense... I remember it took a while to get a diagnosis as some doctors would just tell me to drink more water and I would be fine. I can drink all the water in the world and it wouldn't change the fact that my blood vessels don't constrict like others do. I don't think generally in the ER it would change a treatment plan at all, nor much in the ICU/acute care but it does help in gathering more information? But if there is no universal standard on evaluating it, then it's pretty much a subjective assessment and holds little credibility.

Not usually in urban/suburban settings and only in certain circumstances in the wilderness if you have the qualifications. Not something you should ever be trying though if you can get to a hospital or a place with higher level of medical care.

Didn't mean to imply you thought that at all... So what's the background on this discussion? Are we all nuts for thinking the way we do? Do you have some insider information to share?

Stopped EMS back in 2009 after my 4th surgery... figured I couldn't be lifting patients when my shoulder was so bad if I sneezed it would dislocate. And with all of my joint issues probably not the best thing to be doing...although I do play hockey I left EMS at an EMT-I/99 level and am in nursing school now.

ya

LOL... not always the going in part that is the problem... when a doc has to stand there with their arm against the humeral head to keep it back...that's when we run into problems

My issues started at 5 though, so kids are affected by orthostasis as well. And also why I stated a general consensus... I doubt very often in literature that you will see identical numbers from paper to paper. Hell I can't even find a consistent number of people in the world who have EDS. The overall point I take from reading such articles is a guideline... and common sense. If someone only has a 14mmHg drop in their systolic BP, but states they are dizzy, I'm not going to rule out the possibility they might have some orthosatic issues occurring. Hard facts combined with observation and common sense can help come to a diagnosis. Just because someone doesn't fit into the normal standard or range, does not mean they do not have an issue. And no, I didn't take it as a personal attack, I'm really enjoying this mental stretching and discussion

What if we don't have a cert level and no job to post about I feel left out Dwayne

If I had a nickel for every time an ER doc told me it would be a piece of cake and not to worry, I'd be a millionaire...

http://www.dizziness-and-balance.com/disorders/medical/orthostatic.html http://www.mayoclinic.com/health/orthostatic-hypotension/DS00997/DSECTION=tests-and-diagnosis On the Mayo clinic under blood pressure monitoring, it gives the numbers 20mmHg for systolic and 10mmHg for diastolic changes. http://www.aafp.org/afp/2003/1215/p2393.html Very first paragraph in bold outlines the changes as http://www.sciencedirect.com.dml.regis.edu/science/article/pii/S002234761000764X This gives a general guideline to the time it takes to show a positive orthostatic sign and is from The Journal of Pediatrics. http://journals.cambridge.org.dml.regis.edu/action/displayFulltext?type=6&fid=7854155&jid=RCG&volumeId=20&issueId=03&aid=7854154&bodyId=&membershipNumber=&societyETOCSession=&fulltextType=RV&fileId=S0959259810000201 Seems the general consensus is that symptoms must occur within 3 minutes of position change, and that a change of 20mmHg systolic and 10mmHg diastolic results in a positive test. I know not all will be able to access these articles.. I can e-mail them though to those who wish to read them in depth. I know when I was diagnosed with POTS, it was through a tilt-table test... I kept passing out though and so I received a positive diagnosis without much numerical support.

I think the relevant use in EMS would be, if you go to stand a patient up and they become very dizzy and lightheaded... probably wouldn't hurt to put some fluids into them. I don't believe in increasing on scene time if you don't have to, but I do believe in obtaining as much information about a patient as possible within a reasonable amount of time.

The second picture is probably the best way to sling a dislocated shoulder. That is what I know as the neutral position for the shoulder or the position of use. How often do we have our forearms lay flat against our bellies versus having our arms out a little and to the side? Even as I type this there is a little space in my armpit and my forearms are facing forward. Think about how when a shoulder dislocates what happens. The humeral head in most cases will roll anteriorly and drop inferiorly a little bit. (I'm guessing your friend had an anterior dislocation so I won't go into inferior or posterior dislocations unless you want me to.) When you try to move the forearm across the abdomen and it is still dislocated, you are putting a tremendous amount of stress and pressure on that humeral head. By abducting (moving the humerus away from the body) the shoulder by about 15 degrees, you are relieving that pressure and more often than not easing the patients pain and reducing the muscle spasms. After shoulder surgeries, depending on the type, you will see more and more often now people being placed in what is called an Ultra Sling which has that padding and holds the arm at a more natural position. All in all when it comes to splinting, it's hard to do the wrong thing medically if your patient is more comfortable. ETA: more info.

Looking at that bruising, this guy is in my opinion a high risk pt for pneumonia because of the decreased lung expansion. I figured you would have mentioned it, but it's been a while since I've thought trauma and so my mind just went a little nuts. Thanks for the brain work out

It's been a while since I studied pulmonary contusions, but I would think that watching the trending in sPO2 and CO2 would tell us more about gas exchange condition. With adding artificial O2 to the mix, it would be difficult to tell if this guy was having issues at the gas level? Is it safe enough to guess that the guys only issue in the end was the arm? I'm still curious about abdominal/pelvic injury. Just don't try and mount a 50" flat screen by yourself when you're in your 70's and you'll be good

I didn't see any rib fx immediately on the shoulder xray, but pulmonary contusion could be a huge factor for this guy... the arm was clearly forced into the ribs and that could have been enough to cause a pulmonary contusion...cardiac also....maybe. Also from the amount of facial trauma seen on the first photo, I would be for sure interested in what a facial series looked like as well as a face/brain CT. Since he claims to have been seat-belted at the time, any signs of a lap belt injury? Would have really liked to see pictures of this accident to have an idea of the forces involved, but from the one xray you showed, must have been a good amount of force. Side note...we once had a mid-shaft femur fracture come into us, and he was sitting up and talking completely fine.... Dropped a flat-screen tv on his thigh and snapped it in two. No other trauma occurred. Made me realize that not everything that you would think is a huge trauma, there can be freak isolated injuries that we would normally associate with more complex issues.

As far as time... you shouldn't allow too much time to pass, which is why I always started just as they stood up and so about 30-60 sec have passed before I get a new BP... I know with me, I feel fine for the first second or two and then the dizziness hits.

I always was told a change in BP systolic >20mmHg and >10bpm constituted a positive finding. I always tested the patient on the same arm laying down, immediately after sitting up to a high fowlers type position, and then again when the patient went to standing if possible. I always took the patients statement of feeling dizzy or the symptoms worsening as a positive sign as well. As someone who has POTS, I tried to be pretty acute to S/S that could be orthostatic in nature and when possible and time permitting I would check for it.

It has been pointed out, it has existed for a very long time. I believe my grandfather, a USMC Master Sgt. in WWII suffered from it even to the day he died. I have a very close and dear friend who was brutally attacked and nearly died, who suffers from nightmares, attacked her husband in her sleep because she thought he was harming her, gets panic attacks in public when she sees a bald man...are you telling me she is just weak? She is THE strongest person I know for overcoming what that monster did to her, and is so brave and strong to be confronting it every day in therapy in an attempt to get her life back. How DARE you come in here and just stir the pot with your bull shit. If you don't agree with a post....zip it. I generally ignore your ignorance and rude comments, but this hit too close to home and I am too tired to just sit by and watch. You should really be ashamed of yourself, and I hope your mother finds out how you behave on this web forum, it is truly appalling.