crotchitymedic1986 Posted August 24, 2011 Posted August 24, 2011 I did not say I was giving asa for pain, I said i was giving asa and NTg because it is a possible MI (I would then move to Morphine if Ntg didnt work). Someone then wrote back that ASA does nothing for chest pain, so I answered as I did to be fecicious. Wow DOC you never had your Chem-7 contradict your ER glucometer ? I can not believe you would let a known unconscious diaphortic diabetic patient die because you needed to do a head CT to rule out a CVA. So following all of you guys line of thinking, we should not push Narcan for unconscious patients when we have no evidence of an overdose ? Why would we ever push thiamine, what test do you have to prove the patient is an alcoholic, versus just being drunk today ? Same thing. And I guess we should never backboard an unconscious patient lying on the side of the road, if there is no bleeding or fractures ?
Vorenus Posted August 24, 2011 Posted August 24, 2011 You said: Or do you give the ASA and NTG and see if it improves the patient ? Now explain to me how the diabetic scenario is different. Implies to me, that you`d expect to see a positive result of the given ASA. Since ASA is not thrombolytic, what other result may that be? I answered you: Just to be pedantic: ASA is not going to visibly improve your pt. as you have stated above. Which led you to answer me: {quote]And to be Repedantic, ASA could improve if it is a musculoskeletal issue. And Aspirin reduces blood clotting, which can help blood flow through a narrowed artery that's caused a heart attack, which is probably what is causing the cardiac type chest pain -- but thanks for trying, and no, there is no doubt that I am right on this one.{/quote] Seems to me like you try to justify your opinion that ASA will give your pt. pain relieve - why you`d want to do this if you never ment to state that the given ASA might have this effect, I don`t know. ERDOC, squint and me then told you that ASA`s not thrombolytic, but that it only hinders further blood to clot. Your answer: Well it is obvious that I will never change your mind, so all I can do is pray that your glucometer is 100% accurate, 100% of the time, otherwise there will be a very bad outcome. We have beaten this horse to death, thank you for the debate. That surely a very competent way to lead a discussion... BTW: What do you mean with "fecicious"? Spelling mistake? Looked it up, couldn`t find something?
Just Plain Ruff Posted August 24, 2011 Posted August 24, 2011 If you have never seen a hypoglyemic pt present with stroke like symptoms then you haven't seen very many pts. It is one of the stroke mimics and is the reason we get a blood sugar before even thinking about tPA. Aspirin does not reduce blood clotting. If you think you are giving ASA in an MI to reduce pain then you might want to go back to basic pharmacology. You are not getting any help from the "veterans" because you are wrong. Please stop posting such inaccurate, bordering on false, information. i had a patient presenting like a CVA one night. Left side paralysis, facial drooping, inability to speak. Did a blood sugar, it was 325. Called the helicopter for transport to the stroke center. Repeated the blood sugar and it was 300. Patient put in chopper, still critical, flight ensues. Patient getting worse, nearly causing intubation. Flight crew did repeat blood sugar about 5 minutes out from hospital and it was 40. they gave sugar and he perked right up. Wasted flight, maybe. But what the patients family didn't tell us is that his blood sugar was LOW on their meter and they pumped him full of a entire jar of grape jelly they told the flight crew. We were on the end of the grape jelly working, and by the time the last sugar had been checked the jelly had worn off. Based on my report I flew the guy, but I guess had I have waited 10 more minutes I would have seen the precipitous drop in his sugar as the jelly wore off. What the doctor in the ER said was that the patient's blood sugar had been propped up by the jelly that it was only a matter of time that it would have crashed again. He said the right decision based on presentation was to the stroke center. Hell the patient family didn't even bother to tell us they had given him jelly nor did they think it was important to relay that he was a diabetic. That's what pissed me off most. their leaving that information out cost the guy a 20K helicopter ride or some gawd awful amount.
HERBIE1 Posted August 24, 2011 Posted August 24, 2011 Gawd help me for saying this, but I agree with crochity- to a point. Yes, there easily can be a false reading on the glucometer. Problem is, you need to keep your options open and have a high index of suspicion, and that's when experience takes over. If a patient presents with classic hypo(or even hyper) glycemia symptoms, it should correlate with the reading you get on the machine- especially if the patient is a known diabetic. There have been many times where I do not believe the reading, so I take an extra second to compare results from one machine, run another sample with the second meter we have in our quick response bag to verify the values. If I am getting a reading that says 30, but my patient is fully alert and oriented, I will recheck my readings. Has it happened that a person is extremely low and still functional? Yep. Many times. I have also had people completely unresponsive with a reading of 75. It depends on the patient and their particulars. As for treating chest pain- I don't have the luxury of getting serial cardiac enzymes, or EKG's, so I will be erring on the side of caution for a possible MI. An early stage MI may not be readily apparent. ASA and NTG are relatively innocuous drugs, so other than a possible drop in BP, it's not going to hurt someone, but it may very well save heart muscle or their life. i had a patient presenting like a CVA one night. Left side paralysis, facial drooping, inability to speak. Did a blood sugar, it was 325. Called the helicopter for transport to the stroke center. Repeated the blood sugar and it was 300. Patient put in chopper, still critical, flight ensues. Patient getting worse, nearly causing intubation. Flight crew did repeat blood sugar about 5 minutes out from hospital and it was 40. they gave sugar and he perked right up. Wasted flight, maybe. But what the patients family didn't tell us is that his blood sugar was LOW on their meter and they pumped him full of a entire jar of grape jelly they told the flight crew. We were on the end of the grape jelly working, and by the time the last sugar had been checked the jelly had worn off. Based on my report I flew the guy, but I guess had I have waited 10 more minutes I would have seen the precipitous drop in his sugar as the jelly wore off. What the doctor in the ER said was that the patient's blood sugar had been propped up by the jelly that it was only a matter of time that it would have crashed again. He said the right decision based on presentation was to the stroke center. Hell the patient family didn't even bother to tell us they had given him jelly nor did they think it was important to relay that he was a diabetic. That's what pissed me off most. their leaving that information out cost the guy a 20K helicopter ride or some gawd awful amount. Yeah- sometimes the family is too freaked out to relate to you everything they should. Certainly not your fault, and better to err on the side of caution. I had one family tell me the patient had a seizure, and swore up and down that he had no medical problems whatsoever. His heart was fine, BP fine, no diabetes, no medications... A quick exam revealed he had an implantable defibrillator/pacer which apparently had fired. I pointed this out to the family and they said oh yeah- he has heart problems but his heart has been fine since they put in the device last year. LOL
Happiness Posted August 24, 2011 Posted August 24, 2011 Ok I completely confused. Are we talking MI, Diabetic, CVA or a combination. And when I give ASA it is to a conscious pt not an unconscious one, so please set me on the right path..
crotchitymedic1986 Posted August 24, 2011 Posted August 24, 2011 (edited) Happiness, to save you from reading 5 pages; The original scenario was an unconscious diaphoretic, diabetic patient who has all normal v/s including the glucometer reading of 120. My treatment scenario, after experiencing faulty glucometer readings, was to push 1/2 amp of D50 and see if there was a response (because unconscious and diaphoretic diabetics usually equates to hypoglycemia). All of the newbies said I was crazy and should have my licensed revoked. So I asked if you had a symptomatic chest pain patient but the 12 lead EKG was normal, would you withhold NTG and ASA ? Finally, some rationale voices have joined the conversation, as I have had to argue with the rookies who believe that you should treat the machine before the patient. Thank you all ! Edited August 24, 2011 by crotchitymedic1986
tniuqs Posted August 24, 2011 Posted August 24, 2011 (edited) Yes happy very confusing with the multi thread jacking going on by you know who, point being in this thread was that high blood glucose in the perfusing MI patient is a predictor to outcomes it statred out as an excellent debate hell even this old bastard learned something from a "rookie query" .. where it went from that was "treat the patient not the machine" whatever really. So its open season on any topic now I can not believe you would let a known unconscious diaphortic diabetic patient die because you needed to do a head CT to rule out a CVA. And here's your sign ... someone is going to die !!! OMG Panic give dextrosed based on LOC and sweaty with a bracelet !!! ps ... no one said anywhere they would withhold D50W if indicated.. the follow through was good patient assessment, repeat BGL as in Herbies note and consider ALL the possibilities, CVA, Trauma, MI, OD, ETOH, DTs +++ (apperantly the link provided to Blesoe's Handouts link was ignored) So following all of you guys line of thinking, we should not push Narcan for unconscious patients when we have no evidence of an overdose ? Narcan should never be used as a diagnostic med, little things like depressed V/S, marginal RR, Bradycardia and those pin point pupils, track marks, burnt spoons and hypos can be a "tell" but there are some adverse side effects. Heck the use of fluazamils was dc ed as a direct result of "I dunno lets try this stuff" and find out in a mixed OD .. that WAS part that was benzos and now refractory seizure's needing very big pharmaceutical guns to stop them . EPIC EMS FAIL. Why would we ever push thiamine ? DUH (ever see the IVs of yellow smelly fluid in ER called Berroca C ? ) .. perhaps because of WKE "locked in" and becuase all IDDM alchololics take their vitamines and have awesome diets. Very similar as to giving large volumes of NS in the hyponatremic patient quickly then of course gluconeogenesis and thiamine crazy stuff. http://scholar.google.ca/scholar?q=gluconeogenesis+and+thiamine&hl=en&as_sdt=0&as_vis=1&oi=scholart granted most of the studies are the rat model ... almost seams fitting at this juncture ? what test do you have to prove the patient is an alcoholic, versus just being drunk today ? Unconscious and diaphoretic ? well one never know's, one could have had a DT siezure with no one around as a witness .. hey, its your scenario. btw Seizure as far as call volume is concerned is the highest on current statistical the hit parade, but no .. push the glue first the machine is wrong. Same thing. And I guess we should never backboard an unconscious patient lying on the side of the road, if there is no bleeding or fractures ? ok that's just silly. Happiness, to save you from reading 5 pages; The original scenario was an unconscious diaphoretic, diabetic patient who has all normal v/s including the glucometer reading of 120. My treatment scenario, after experiencing faulty glucometer readings, was to push 1/2 amp of D50 and see if there was a response (because unconscious and diaphoretic diabetics usually equates to hypoglycemia). All of the newbies said I was crazy and should have my licensed revoked. So I asked if you had a symptomatic chest pain patient but the 12 lead EKG was normal, would you withhold NTG and ASA ? Finally, some rationale voices have joined the conversation, as I have had to argue with the rookies who believe that you should treat the machine before the patient. Thank you all ! Absolutely incorrect .. that's your thread High Jinks as is your provocative no such thing as PTSD, just weak of mind, then mercury used as preservative causes Autism, then of course your favourable ME thread Whitey put me down. ERDoc has suggested that we don't respond to crotch's delusional musings .. personally the knee jerk posts that crotch makes and my responses is not as a result of any annoyance its more ... well ... as quoting Charlie Sheen .. It simply amuses me and entertainment value. Please crotch keep it up, I have lots of time on my hands to respond to your irrational rants, I enjoy blowing holes in your vast knowledge of EMS. cheers Edited August 24, 2011 by tniuqs
crotchitymedic1986 Posted August 24, 2011 Posted August 24, 2011 You killed your patient because you have absolute trust in equipment, you blew a hole in your credibility
tniuqs Posted August 24, 2011 Posted August 24, 2011 (edited) I blew a hole in my credibility ... interesting that. Although I did change my avatar as I love looking for Pirates to walk the plank, har har my dark well hung beauty .. you have been hoisted by your own arrogant petard. Should I apologise to hutsy or perhaps get back on the rails with this most valuable topic ? ]Quoting ME. An excellent find have learned something today I do remain sceptical about elevated BGL in any arrested patient for any length of time, this will undoubtedly result in decreased BGL, due cellular metabolism, complicated by anaerobic respiration, lactic acid production +++. besides I am under the impression (could be wrong) there are accuracy limits when typical BGL evaluation in regards to PH. We have come a long way from drop the blood on a stick, wait a certian time and compare to now with jump drives that do record keeping graphs and spread pages. This topic has really piked my interest in regard's to delivering hypoglycemic agents at the critical care level in the field during cardiogenic shock. If cardiogenic shock is being treated and hyperglycemia is documented. I will now be doing BGL on all Chest Pain even if no IDDM is the history, I did not in past. I have been doing bedside troponin as a diagnostic guide and am pushing to get these on car in my hood. Evidence Based Medicine now entrenched in EMS / AHA these day, this study is suggesting that their is a decreased morbidity mortality. Could this study be pointing the way for improved delivery of pre-hospital care ? That said, the study is a prognosis indicator and not if relative hyperglycemia "treated" reduces mortality, (from what I read) then of course funding for a study in EMS .... hmm well ..... not a lot of cash for that these days. Second thought getting into the books / studies, the increase in blood glucose is marginal (~ 9.2 ) to be using a typical insulin sliding scale (yup and controversy there too) as the sliding scales are used in know IDDM only, then, giving insulin SQ with decreased perfusion. Well it could be more more complex for my lil bean. Historically insulin has not been used to treat hyperglycemia in EMS, bucking the old school could be an issue as well. Perhaps other hypoglycemics could be trialled, maybe worth some time in a follow up with a researcher. I know one a few doing transplants with islets of langerhan in livers at the University Hospital in Edmonton and having great success. cheers Quoting very respected jstalmm: Just did a bit more reading today, as far as the evidence based stuff is concerned, treating with insulin isn't yet a standard practice, but may have its benefits. I think some of the intensivists/ED physicians down my way treat stress hyperglycemia, but definitely isn't a norm as far as I know. Also, I think there are still some issues regarding whether or not the sugar actually causes harm or if it's just an indicator. From personal experience I can recall one recent cardiogenic shock patient, initially with a BSL of 9mmol or so, on arrival to emerg about 30mins later who had a BSL of 20+...needless to say he followed the trend Care to positively contribute to the real thread crotch or continue your "the machine was wrong" "I am right and you kilt a patient" LS said it best ... Kill em in the classroom so they live on the streets. NO one has ever said it better in my books, sure wish I could staff a fixed winger with LS as a partner... we need that attitude up here in Kanukistan. crotch well not so much ... but a black friend in LA Acadian EMS FTO (call sign zantelhunt) thank my god I know a great paramedic that just so happens to be black as well as EMT-B saint Mikey and Videl, and Ferguson Kennedy in the Commonwealth of Dominica who would put you to shame dear crotchety in there knowledge of "bush EMS medicine" OMG thats the rhum speaking I so hate when that happens ! Edited August 25, 2011 by tniuqs
Vorenus Posted August 25, 2011 Posted August 25, 2011 Happiness, to save you from reading 5 pages; The original scenario was an unconscious diaphoretic, diabetic patient who has all normal v/s including the glucometer reading of 120. My treatment scenario, after experiencing faulty glucometer readings, was to push 1/2 amp of D50 and see if there was a response (because unconscious and diaphoretic diabetics usually equates to hypoglycemia). All of the newbies said I was crazy and should have my licensed revoked. So I asked if you had a symptomatic chest pain patient but the 12 lead EKG was normal, would you withhold NTG and ASA ? Finally, some rationale voices have joined the conversation, as I have had to argue with the rookies who believe that you should treat the machine before the patient. Thank you all ! Sure enough, only the comments that agree with you are rationale... You`re just pathetic. Not sure if you even realize that you make yourself ridiculous? And no, of course I didn`t expect an answer to my latest post, seeing that you would need to make a precise answer and of course that`s beyond your capabilities.
Recommended Posts