How would you handle the care for these Pts

[Smash]

Roadside open laparotomy?

I am going to adopt Brown.

Why stop at an open lap? Go the full crack I say: "Brown, the rib spreaders please..."

 

[MrBrown]

Why stop at an open lap? Go the full crack I say: "Brown, the rib spreaders please..."

Hang on, we'd better tell the patient

"Now look here mate, this is going to hurt pretty bad I'm not going to lie and there is no other way to put it but we have to do it to keep you alive. Try to think of something nice and just go with that man"

Somebody get me 2mls of ketamine to start and dilute it up to 20, thats 200mg, what, maybe give the whole 200, should knock them out you think?

 

[1badassEMT-I]

It's not completely awful if the textbooks are slightly outdated, so long as they stay away from medical statements that are fundamentally wrong. Information about MAST systems is tempered by the fact that many systems don't carry them anymore. Also, protocols should serve to keep everyone on track.

That said, my class is using an older version (8th ed) of the Brady textbook, and it is obvious that a good amount of the information is either outdated or plain inapplicable. Almost everything that they teach us about PCRs is inapplicable to our county's system. Also, stuff like use of the PASGs is talked about like it's still in use.

Hey we got PASG on our trucks.....they take up space and collect dust.

 

[usafmedic45]

I said for fluild administration didnt say DROWN THEM!

LOL ...and they just wanted to make sure you weren't saying that. Don't be so defensive. Sasha doesn't bite...unless asked. Even then, you have to ask nicely.

Somebody get me 2mls of ketamine to start and dilute it up to 20, thats 200mg, what, maybe give the whole 200, should knock them out you think?

Worked in Viet Nam.

WOW never over 10lpm that interesting!

Not really. If they are not oxygenating adequately with an FiO2 of >60 or so, there is something pretty wrong and chances are good that throwing more oxygen alone at the problem is not going to solve it.

Also for us atleast in some extremes of the county air transport is 5-10 minutes and ground is 30-50 depending on traffic

Yeah, but by the time you factor in all the issues already mentioned beyond the simple scene to hospital flight time, even with a 30-40+ minute ground transport chances are good that a patient sent by ground would be at the hospital 5 to ten minutes ahead of the helicopter transported patient. This is assuming that the ground crew transporting the patient did not sit on scene and screw around.

As for transport decision making, no call for the helicopter indicated in this situation. Unless you're close to an hour out, there is no justifiable reason to call for the helicopter. A properly equipped and trained ALS ground unit can do most of the things this patient will need and can deliver them faster and easier while delivering the patient to the things that they can't.

When it comes to vascular acess, I would probably put a single 16-18 gauge in and would either do a saline lock or at most a TKO drip.

 

[mycrofft]

I think "Scenarios" are an aquired taste.

The best one can do is give one's working hypothesis on approach and initial response, then it degrades into a jungle of "What about/Yes, but", "NIGYYSOB", and flowcharting.

So much of the art of medicine, even as a nurse or a tech, is WATCHING the pt and adapting tx to s/s. The science is know which measure or insult is causing the bad things to happen..or the good things.

The field worker's art specifically is know what to treat before transport, during transport, and the best way to transport.

Oh, and billing info collection!

 

[irish_handgrenade]

Look for obvious fractures, spinal injuries, head injuries, internal bleeding from organs or long bone fractures, and possible tamponade/pnuemos.
Assess mental status -> rapid trauma assessment -> extricate -> full spine immobilization -> reassess-> assess vitals -> O2/monitor -> I agree with 2x IVs, but I would saline lock one, and put fluids to the other, if BP is above 90 systolic I KVO unless trends in BP show the pt does need a fluid bolus-> rapid transport, If the local ER (30 minutes away) is not a higher level trauma center I would either have a flight crew meet us enroute at the ER or enroute to a higher level facility. There is no reason delaying definitive care if the closest ER is not a high enough level trauma center.

And as for your little tif with sasha, dude you kinda flipped off the deep end, there is no absolutely correct answer to any scenario and if you are going to make it in this business you need to understand that EMS is 95% gray area, and 5% black and white. Also you should not wear your feelings on you sleeve cuz they will get blood, poop, and vomit on them...

 

[Sasha]

Don't be so defensive. Sasha doesn't bite...unless asked. Even then, you have to ask nicely.

Or talk dirty to me.

Yeah, but by the time you factor in all the issues already mentioned beyond the simple scene to hospital flight time, even with a 30-40+ minute ground transport chances are good that a patient sent by ground would be at the hospital 5 to ten minutes ahead of the helicopter transported patient. This is assuming that the ground crew transporting the patient did not sit on scene and screw around.

I think a lot of people forget that a helicopter is not always better, and you have to think ahead and do the math and make sure there is actually a benefit to the patient for HEMS transport, and that it's not just something you can go back to your buds and tell them about the "cool trauma call" that you worked that was so bad you sent them out by helicopter. Even if they can get them to the hospital faster, it may not always be in the best interest of the patient.

 

[usafmedic45]

Or talk dirty to me.

Duly noted but my fiancee would never go for that.

Even if they can get them to the hospital faster, it may not always be in the best interest of the patient

Yeah, medical care in the back of a helicopter is extremely limited. Aeromedical operations may have a lot of "cooler toys" but several of them it's damn tough to use in flight, which is one reason why scene times for truly critical patients being flown out are much longer than we should be comfortable with. Intubations in a lot of helicopters is much harder than doing it in the back of an ambulance or on scene.

 

[Veneficus]

The best one can do is give one's working hypothesis on approach and initial response, then it degrades into a jungle of "What about/Yes, but", "NIGYYSOB", and flowcharting.

So much of the art of medicine, even as a nurse or a tech, is WATCHING the pt and adapting tx to s/s. The science is know which measure or insult is causing the bad things to happen..or the good things.

The field worker's art specifically is know what to treat before transport, during transport, and the best way to transport.

Oh, and billing info collection!

I think a scenario should be instructive and present information for the purpose of critical thinking or debate.

It should not simply be a "war story" or a "guess what I am thinking" excercise.

It also really bugs me when a complete physical and history is not presented and the author wants somebody to ask about every detail. Some findings are grossly apparent and just my brief looking over of a patient can yield considerable information before I touch them, which is absolutely certain to be next.

 

[Melclin]

Or talk dirty to me.

*spits coffee over keyboard and desk in surprise*

You gotta be careful throwing talk like that around. You're likely to kill a bloke.

God dammit Brown, you gotta give me some warning if your choppers going to start tubing small horses, or the Prescribing Authority is ganna start thinking you're nicking some ketamine on the side and selling it to glassy eyed ravers.

Whenever I think of "extending to a clamshell" when cracking chests, I can't help but think of that talking hamburger that flogs McDonalds. Odd.

 

[usafmedic45]

I can't help but think of that talking hamburger that flogs McDonalds

In the quiet words of the Virgin Mary: Come again?

 

[MrBrown]

God dammit Brown, you gotta give me some warning if your choppers going to start tubing small horses, or the Prescribing Authority is ganna start thinking you're nicking some ketamine on the side and selling it to glassy eyed ravers.

Not likely, we carry 200mg in 2ml and inject the whole thing into a pack of 5% dextrose to make 10mg/ml.

The max dose we can give is 150mg ... now I have never seen anybody get 150mg of ketamine but I immagine they would be quite nicely "disassociated"

 

[jjesusfreak01]

Would 200mg put them at the borderline for losing spontaneous breathing control?

 

[MrBrown]

Would 200mg put them at the borderline for losing spontaneous breathing control?

I am not sure, I am not an anaesthetist

Ketamine's main mechanisim of action is not on the opiod or respiratory centres so does not depress respiratory drive. If anything it has a pro-respiratory and some bronchodialatory effects which make it great for asthmatics.

For prehospital RSI we give 1.5mg/kg, up to 150mg in combination with 1mcg/kg of fentanyl.

I have been meaning to pinch one of the anaesthetic reg's or consultants and have a chat about ketamine.

 

[jjesusfreak01]

Right, but enough of a dissociative will cause complete dissociation wherein the patients body will stop breathing because it no longer realizes that it needs to (or something like that). I am specifically thinking dxm overdose, but I would imagine ketamine would have a similar effect at high doses.

 

[MrBrown]

I am not sure to be honest mate, I'll have a look after work.

You know I just bought this "DOCTOR" jumpsuit for seven hundred pound online right?

 

[LondonMedic]

Ketamine's main mechanisim of action is not on the opiod or respiratory centres so does not depress respiratory drive. If anything it has a pro-respiratory and some bronchodialatory effects which make it great for asthmatics.

It can cause apnoea in overdose or overly rapid administration and does cause decrease in minute volume in paeds.

 

[usafmedic45]

For prehospital RSI we give 1.5mg/kg, up to 150mg in combination with 1mcg/kg of fentanyl.

Why benzos? Why fentanyl? Adding an analgesic to anaesthetic seems kind of redundant and if you are working on an adult there is that spectre of an emergence reaction if you for some reason forget to keep the patient under. When we use it- both in hospital and out of hospital- it's usually paired with lorazepam or midazolam.

Personally, it's one of my favorite drugs for RSI, especially in asthmatics or hypovolemia. I am glad to see that some progress is being made in reversing the long held bias against giving it in patients with head trauma now that it has been shown not to cause increases in ICP (and God only knows whenever they put out a new album it will be too soon. ) and that it may have clinically significant neuroprotective effects.

 

[MrBrown]

Honestly I do not know, I think fentanyl has some sedative / amnestic / sympathetic tone agonist features but I am not sure.

Mind you how many anaesthestists give a pre-med? Lots.

I hear ketamine will only produce anaesthesia for about ten minutes, much the same as etomidate and propofol. I dno tho, last time I got hit with propofol several hours went by, although I do remember a tank of sevroflurane being present

We follow up the ketamne and fentanyl with some midaz, not really to play anaesthetist but to keep the patient sedated enough where they dont remember.

 

[Melclin]

In the quiet words of the Virgin Mary: Come again?

Flog = sell

There used to be a big talking hamburger that bounced around on the teli (TV) flogging (selling) maccas (McD's) to kids. But they banned him because parents are too stupid to realise/to lazy to take responsibility for the fact that a regular diet of lolies (candy), maccas and coke would make their children fat.