Blood sugar levels

[BushyFromOz]

My left arm for a dislike button....

Deffinately and ankle crotch, deffinately an ankle.

[systemet]

No, but I can spot a dissection from a mile away (either through my xray vision, or God tells me according to you guys).

How do you do this? How many TAAs have you seen? In what percentage of the times that you thought you saw a TAA were you right? In what percentage were you wrong? How many patients have you evaluated who you didn't think had a TAA? How often were you right? How often were you wrong? How do you feel this compares to assessment by a ER fellow? IM / Cardiology?

Can you beat U/S or mediastinial changes on CXR? How do you compare to thoracic CT?

What makes you think that you can do this better than everyone else? With less education, and less technology? Physicians in the ED with a million times more experience, education and training time, and better technology miss these on a regular basis.

That is the whole point, I have seen too many medics treat the equipment instead of the patient. The overuse of technology has made you guys weak in assessment.

Has it? Perhaps it has, I don't know.

Or has an increase in education made us more aware of diagnostic uncertainty? Are we better able to understand the limitations and benefits of the technology available to us?

I can tell the difference between Dyspnea that is caused by left sided heart failure, early COPD, or Pnuemonia, or pleurisy in a patient with no history of any respiratory ailments

I can't. I can identify clear presentations of any of these conditions, but I can't always differentiate them in a complex setting.

And perhaps it's because I'm too reliant on technology, and that my physical examination and history taking skills are inferior to yours. Or possibly it's because I know that each of these diseases can occur in the presence of the other. Perhaps I also know that physical exam has limited diagnostic utility for either condition. Perhaps it's because I know that they can look almost identical in early presentations.

Or perhaps it's because I know that even far better trained and educated ER physicians routinely misdiagnose CHF and pneumonia patients because even with better technology, e.g. labs, U/S, CXR, cultures, there remains a lot of diagnostic uncertainty.

Most Docs can't without a chest xray and a BNP (lab test).

So, just so I understand your position -- you're a paramedic (like me). You've had (maybe) 3 years of education specific to "medicine". You've worked in an ambulance, or perhaps a fixed wing or helicopter for a number of years. And now you feel that you can better diagnose disease states than a physician with a 4-year BSc, 4-year MD, 5 year ER residency, and years of clinical practice. A physician who probably sees more patients in a shift than a medic sees in a tour, who's had extensive rotations through every medical specialty (not just 2 weeks in the OR, 2 weeks in case room, a couple of weeks in CCU, and a couple of days in NICU), and has imaging technology and the ability to get chemistry / microbiology. And you think that you're better than that?

Because if you are, we should start collecting money. All of us. And we should send you to Harvard or Yale, or Columbia. you can go talk to the Dean of Medicine there, and show them what they're doing wrong. We can shorten physician training down to 3 years, sell of all the CT machines, get rid of the U/S, put all the RTs on welfare (sorry guys!), close all the medical schools, and you can show them how it's done better.

And I can tell you most of you miss it when it is left sided heart failure, and you end of giving an albuterol/atrovent treatment, and atrovent is contraindicated in CHF. So who is practicing bad medicine now ?

I'm not going to get into the quagmire that is beta-agonists in CHF. Don't have the energy.

Am J Emerg Med. 2010 Oct;28(8):862-5. Epub 2010 Mar 25.

A multicenter analysis of the ED diagnosis of pneumonia.

Chandra A, Nicks B, Maniago E, Nouh A, Limkakeng A.

Source

Department of Emergency Medicine - Duke University Medical Center Durham, NC 27710, USA. abhinav.chandra@duke.edu

Abstract

OBJECTIVES:

The objective of this study was to describe the prevalence of pneumonia-like signs and symptoms in patients admitted from the emergency department (ED) with a diagnosis of community acquired pneumonia (CAP) but subsequently discharged from the hospital with a nonpneumonia diagnosis.

METHODS:

A retrospective, structured, chart review of ED patients with CAP at 3 academic hospitals was performed by trained extractors on all adult patients admitted for CAP. Demographic data, Pneumonia Patient Outcomes Research Team scores, and discharge diagnosis data (International Classification of Diseases, Ninth Revision [iCD-9] codes) were extracted using a predetermined case report form.

RESULTS:

A total of 800 patients were admitted from the ED with a diagnosis of CAP from the 3 hospitals, and 219 (27.3%; 95% confidence interval [CI], 24-31) ultimately had a nonpneumonia diagnosis upon discharge. Characteristics of this group included a mean age of 62.6 years, 50% female, and a history of congestive heart failure (CHF) (14%) or cancer (12%). After excluding patients with missing data, 123 patients (65%) had an abnormal chest x-ray, and 13% had abnormal oxygen saturation. Cough, sputum production, fever, tachypnea, or leukocytosis were present in 91.5% of this cohort, and 63.8% had at least 2 of these findings. Twenty alternate ICD-9s were identified, including non-CAP pulmonary disease (18%; 95% CI, 13-24), renal disease (16%; 95% CI, 13-19), other infections (9%; 95% CI, 7-11), cardiovascular diseases (3%; 95% CI, 2-4), and other miscellaneous diagnosis (28%; 95% CI, 25-31).

CONCLUSIONS:

Our data suggest that the ED diagnosis of CAP frequently differs from the discharge diagnosis. This may be due to the fact that a diagnosis of CAP relies on a combination of potentially nonspecific clinical and radiographic features. New diagnostic approaches and tools with better specificity are needed to improve ED diagnosis of CAP.

Copyright © 2010 Elsevier Inc. All rights reserved. PMID: 20887906 [PubMed - indexed for MEDLINE]

[BushyFromOz]

excellent excellent response sys, im really looking forward to reading more of your posts man, your gonna be an asset to these forums

[Lone Star]

excellent excellent response sys, im really looking forward to reading more of your posts man, your gonna be an asset to these forums

I wholeheartedly concur with your findings on this subject, Bushy. I sat here reading Systemet's response while drinking my first cup of the day; and by the end of the post, I was crying 'uncle' (and I wasn't even the one to make an offending statement)!

:bonk:

I am but a poor medic student, please show mercy upon me due to my lack of complete education!

The television show "Emergency!" showed a couple episodes that almost seem inspired by this very thread. I ended up watching them because of this thread....what a vicious cycle!

http://www.hulu.com/watch/47100/emergency-trainee

http://www.hulu.com/watch/12088/emergency-problem

*Edited to add last statement and links to full episodes

Edited August 26, 2011 by Lone Star

[Happiness]

Oh again it has happened. I read these forums and something happens so to put alittle twist I think the following senerio (my yesterday) will put a question to your ability for diagnosis in the field. This call kind of supports Crotches argument (omg i said that out loud), but it also will support the limitations of field equipment and I have always agreed that you should treat your patient but most important you should LOOK at your patient, but that can even be decieving.

Called 28 yr old Man down unresponsive 9 am

Scene (its safe) As you approch the scene you see a male, supine, wearing light clothing with a hoodie laying in tall damp grass. The temp is about 8 celsius. The RCMP officer tells you as you are starting your RBS. The males name and that he had called at 3:40 am his phone provider stating that he was going to take all of his pills. The RCMP officer also say's they have been looking for him but where unable to find him until now.

Hx Mental illness, perscription drug abuse, street drug abuse (extacy and cocaine), ETOH abuse. Prior intervenus drug use. (you know this because he is a family member)

Primary Survey

Skin-border line pale and normal color (no cyanosis), cool, and damp, there is also no motteling in the limbs.

Airway is open

Breathing is present

Radial Pulse easily felt

Eyes- Pin point 1 and not reactive

GCS-3

No signs of trauma

Patient placed on stretcher and put in Ambulance (as this is a small town (gotta luv it) you are able to have someone call the Mother and have her meet you at the hospital with his perscribed medications)

Secondary survey

BP 118/80 (you have cut off shirt and hoodie and notice old scaring from track marks, no fresh ones)

Pulse 103 regular

Breathing 10 effective

O2 is 95% (you put 02 on my mask @ 10 liters sats go to 100%)

You are unable to get a BS as his fingers are cool and refuse to bleed (as you are trying to push out the blood he makes a weak attempt to withdraw (but just so slight))

You administer your Narcan sub q as you are unable to find a site for an IV. (patients GCS goes to 5 (pain response, sternum rub) and immediatly returns to a 3.

You are 3 minutes from the Hospital

You arrive and you give your report to the nurses, they go and do their thing, get lab in, and start their Narcan protocols. Also get a temp of 34.5, so warming protocols start.

The mother arrives with a plastic bag of empty pill bottles approx 30 most empty. So many I just handed to the doc and said good luck. He had taken all of the ones that make you sleepy, Lorazipam, T-3's etc. Labs come in and they have confirmed most of the drugs in his system with the addition of cocaine. Also his potasium was at 7 (just thought I would put that in for those who may understand that stuff). Potasium on the second set of labs went down to 3.

After and hour and a half of pushing Narcan his GCS dosnt go above 5 and will immediatly drop to 3. His vitals stay stable but he wont wake up. Dr is Medivacing him and intibates for airway protection.

Crew comes in and does their thing and then we are off to the plane. I had a minute to ask the medic this specific question, "why do you think he wont wake up?". His answer was that because of all of the drugs (some last longer than others) and the combination of them, they may have cause hypoxia of the brain. He even said "even though your pulseox registered 95% when you messured him, it is NOT going to tell you what the 02 levels are deep in the body going to the brain and remember that he was out in the cold and damp and that is a big contributing factor."

Im pretty confident that my treatment was good and well thought out, but was my equipment wrong or was it just not able to do something that we may feel it should. Now since his sats went up immediatly and his airway was open I did not bag him. Now if I did bag him would it have made a difference in his O2 levels deeper in the body, my mind thinks so but with the drug influance I'm a bit at a loss on this one.

Sorry it was long but I felt if I didnt give you the whole story it wouldn't make much sense. I asked his mother before she was able to get on the plane how he was and she stated that he hasn't woken up yet. Im not sure if he is still intibated or not as she is not a good communicator.

[crotchitymedic1986]

Thanks happiness, for your post, but now you have learned something you will never forget. As to those who question my talent, that you see as impossible, let me ask you this ? If I had been in construction for 25 years, and during those years I worked in all sides of the field, residential, commercial, industrial. If I had built everything from dog houses to skyscrapers in those 25 years, do you think I might know more than the apprentice who is just starting out. If I worked in the day when I had to build my own roof trusses versus having them premade and delivered on a truck, do you think I might know more than the guy who uses the prebuilt trusses. If I had to cut all of my wood with a handsaw instead of a machine, and if I actually hung the sheet rock instead of subbing it out, would I know more than today's rookie builder ?

The same is true for me, I have been in this 25 years, I have worked rural and urban 911, private services, critical care transport, and worked in several emergency rooms (one of which was a trauma center). In the first ER i worked in, we had to call the doctor in from home. I was working when there was no glucometers, pule-oxs, 12 Lead, capnography, IV pumps or even dial-a-flows. I am not smarter than anyone in the room, I have just seen alot more, and like happiness just showed us, I learned from my mistakes.

In the future, when I share wisdom, I hope it will be greeted more positively, as I am only trying to keep you from making mistakes. If you do not appreciate the wisdom then just turn away, there is no reason for all this vitreous language and name calling. Thank you. Let's be adults.

Edited August 28, 2011 by crotchitymedic1986

[Happiness]

Thanks happiness, for your post Your welcome, but now you have learned something you will never forget In reality this will always be in the back of my mind but it wont stop me from still using my equipment for its indended use and if you look I still followed my protocol and I didnt just jump into giving him Narcan. As to those who question my talent Maybe if you use words like experience instead of talen you may get better responeses, that you see as impossible Its your attitude thats impossible, let me ask you this ? If I had been in construction for 25 years, and during those years I worked in all sides of the field, residential, commercial, industrial. If I had built everything from dog houses to skyscrapers in those 25 years, do you think I might know more than the apprentice who is just starting out I have seen alot of shady construction from those with 25 yrs of experience, just because you have been doing something for a long time doesn't make you good at it. If I worked in the day when I had to build my own roof trusses versus having them premade and delivered on a truck, do you think I might know more than the guy who uses the prebuilt trusses Nope the guy using prebuilt is saving time and there fore saving money,. If I had to cut all of my wood with a handsaw instead of a machine, and if I actually hung the sheet rock instead of subbing it out, would I know more than today's rookie builder ? No they just a different way of doing it, and different isn't wrong.

The same is true for me, I have been in this 25 years, I have worked rural and urban 911, private services, critical care transport, and worked in several emergency rooms (one of which was a trauma center). In the first ER i worked in, we had to call the doctor in from home. I was working when there was no glucometers, pule-oxs, 12 Lead, capnography, IV pumps or even dial-a-flows. I am not smarter than anyone in the room, I have just seen alot more, and like happiness just showed us, I learned from my mistakes. I didnt make any mistakes and if you learned from yours Crotch you would stop trying make us think you are always right and quit trying to prove us all wrong. I will agree there are a few comments that you have made through out the years that make sense but you always have to cross that line that makes you look like you might be intelligent to the other side of us just thinking your an ass.

In the future, when I share wisdom How about you present your wisdom with a better attitude, I hope it will be greeted more positively It would be if it was presented that way, as I am only trying to keep you from making mistakes Well quit trying to do that we all make mistakes and your mistake is not nessassarily going to be mine. If you do not appreciate the wisdom then just turn away And if you dont have anything constructive to say and just want to stir the pot then you also can just turn away, there is no reason for all this vitreous language and name calling Fair enough but there is also no reason for all of your racist remarks because we dont agree with you. I am not a racist just like the others here and not everything here is to repress the black guy that posts here. Thank you Your welcome. Let's be adults Remember that statement includes you.

So you know Crotch I didnt post this to prove your point in any way. I wanted to share something that pertained to this thread. Also until you post with the attitude that you are not above us, you will always get the same responses, so learn from your mistakes as you have stated you have the ability to learn from them.

[Vorenus]

In the future, when I share wisdom, I hope it will be greeted more positively, as I am only trying to keep you from making mistakes. If you do not appreciate the wisdom then just turn away, there is no reason for all this vitreous language and name calling. Thank you. Let's be adults.

Funny.

So, if you`re wisdom is that widespread - why do you keep going with the statements that are obviously wrong?

Ah... sry, I get you now - all you say is wisdom and everything else is bullshit. Yep, that`s gonna be it...

[ERDoc]

[Vorenus]

Aaaaaahhhhh... cute kitty