— Dylan Thomas, In Country Sleep, and Other Poems (via books-n-quotes)

EMERGENCY MEDS 20: Magnesium Sulfate

(pls excuse my nails)

CLASS: electrolyte, tocolytic, smooth muscle relaxant.

MOA:

- decreases myocardial and neuromuscular irritability

- inhibits muscular irritability.

INDICATIONS:

- Torsades de Pointes (which I personally refer to as the Angry Tortilla rhythm, since it looks like a side view of someone angrily flapping a tortilla around)

- Hypomagnesemia

- pre-term labor

- pregnancy induced hypertension (pre-eclampsia/eclampsia)

- hyperreactive airway (severe asthma)

CONTRAINDICATIONS

- use carefully in patients with impaired renal function and pre-existing heart blocks

ADVERSE REACTIONS

- hypotension

- flushing

- heart block

- asystole (yay)

- respiratory depression

- drowsiness

- hypothermia

- depressed reflexes

- nausea

ADULT DOSE

Torsades

- 1-2 grams IV diluted in 50-100 ml NS or D5W over 1-2 min, then same amount infused over 1 hr. 

Hypomag

- 1-2 G IV diluted in 50-100 ml NS or D5W over 5-60 min

Resp/asthma

- 2 grams IV diluted in 50 ml NS or D5W over 5-10 min

preterm labor

- 4-6 grams over 15-20 min

PIH/pre eclampsia/eclampsia

- 3-6 grams over 10-15 min

NOTES

- O2 should be administered to patients receiving magnesium

- continuously monitor cardiac status for prolonged PR and widening QRS

- keep calcium chloride readily available in case you screw up and accidentally case magnesium toxicity

- eclampsia can occur up to 6 WEEKS after delivery (so don’t be a jackass)

Every dam time….

When you explain the labwork and imaging results to the pt and explain all the deadly stuff you were able to rule out but the pt refuses to leave because “YOU ALL DIDN’T FIGURE OUT WHAT WAS WRONG WITH ME!!!!!”

EMERGENCY ROOM. Not “figure out what is exactly going on with you” – please follow up with your PCP

SO. This lady came in and said “I have this pain that started 2 days ago. right here *points to epigastric region.* I ate some ribs and went to bed and it just gets so much worse when I lie down!”

so of course I asked “do you have a history of Acid Reflux?” and OF COURSE she said yes. Then she goes on to say “I don’t think I’m having a heart attack. but this is really bugging me.” and I AGREED. We were about to discharge this lady straight up but the doctor was like “eh, it’s slow, lets just do it by the book.”

I got the blood and asked the medic to do the EKG as I ran a bedside troponin level. the troponin resulted as 10.83 (and we get worried when it’s 0.02). and as it results, I look at the EKG and my jaw literally dropped as I watched the significant depressions in V2-V4 come accross the screen.

I felt terrible the rest of the day. We almost let her go home like that. 

KNOW YOUR HEART ATTACK SIGNS IN WOMEN.

Atypical chest pain.  If anyone has cardiac risk factors, you have to work them up for cardiac sources and rule that out. 

classically chest pain we know from ischaemic heart disease or myocardial infarction etc. is from the LAD territory. 

however, inferior MIs on the back side of the heart is closer to your GI tract. So you get heart burn as symptoms. 

equally important to be aware of is silent MIs in diabetics as well as in women. 

I remember my first IM rotation as a student, a gaggle of four of us nearly missed stable angina because literally everything sounded like regular old GERD. we admitted him anyway just to be safe, sure enough dude’s got three vessel CAD and got transferred for therapeutic cath

About 8 years ago, I responded with a volunteer ambulance for a difficulty breathing call at around 2AM. Sounded like classic anxiety: a parent’s funeral was the day before, a child had died last month, she was OK when she went to bed, then woke up screaming and hyperventilating just before her family called 911. Mid-50s, history of anxiety, otherwise healthy. Still hyperventilating with clear lung sounds and no increased work of breathing. Tachycardia, mild hypertension, oriented to person, place, and time, but had forgotten the recent traumatic event. Denied chest pain, denied n/v, denied diaphoresis. So I’m thinking this is anxiety related, but she’s still complaining of SOB, so I’m riding in anyway. On my way out the door, I was checking in with the family to make sure I had the details straight, and her spouse suddenly recalled that she had woken up a few hours earlier, told him that she had chest pain, sat in the living room with him for about 45 minutes, then went back to bed. So I think, “Eh, still sounds like anxiety. But I guess I should do an EKG.”

So I do an EKG. 3-4mm ST elevation in inferior leads. Called a STEMI alert and took her directly to the cath lab: 98% RCA occlusion. 

I have never been more shocked in my life. I would have BET MONEY that it was anxiety. Given the same situation, I would probably bet money on anxiety again. But it should not have taken the spouse remembering the previous chest pain to get me to do the EKG. Lesson learned.

A new police officer walks up to our already secured scene and asks what happened. I responded “well constable… inebriated chap A alluded that status of inebriated chap B’s Jib was unexceptable, to which inebriated chap B responded that the "cut of his jib was entirely beyond reproach”… Fisticuffs followed resulting in the present mayhem and melee… the officer just blinked at me

NHS ambulance

Yeah… that seems correct.

What does your steth say about you?

P.S. if anyone helps me turn the digital cardio deluxe into reality that would be awesome…

One of my old partners got pulled in for an investigation today. The photo is not of him - it’s of a paramedic in California trying to eat something for the first time in nearly ten hours.

My old partner was told that a member of the public took photos of him and his current partner. My buddy was sleeping, and his partner was eating. This member of the public sent the photos with an email that both complained about how “unprofessional” it appeared - and a threat to send the photos to the media.

Thanks to Prop 11 in California, first responders no longer have a right to breaks. AMR lied to the public in a huge way. California was the only state where emergency crews had been granted a legal right to breaks to use the latrine and have a meal. Shifts run a minimum of 12 hours, often 24, and AMR runs their crews into the ground.

My buddy and his partner are in trouble because they were trying to get rest and food while posted on a street corner because we don’t get breaks. This is what AMR tells us to do. Please don’t see something like this and assume that we’re being lazy or not doing our jobs. Don’t take photos or send them to the press. That crew is probably exhausted and overworked.

Not to mention they hold us 911 coverage units over regularly “for just one last transfer call that will be really quick.” When there are plenty of transfer only units posted at hospitals doing nothing at the beginning of their shifts. It also tanks our levels and leaves a lot of the city uncovered for emergency calls.

The thing is everytime you complain about something like people taking breaks, it’s not that you gain something from It, you just make life worse for other people. How about minding your own damn business?

Seems like common sense that people doing a high-stress job that requires a lot of good judgement on matters of life and death should be able to eat and piss when they need to

That really sucks, I can’t imagine what anyone would actually gain by not allowing first responders to have breaks, but it seems ultimately unsafe and unfair, as well as unnecessary. It reminds me of when we had something similar in 2014, when certain trusts in the UK banned NHS staff from drinking hot beverages in any visible areas in case people thought they were slacking. Spokespeople at the time said that  “Clearly this activity has given the wrong impression to staff and the public that clinic staff are not working as hard as they might be.”, “Members of the public are frustrated by long waiting times during clinics and for appointments and are inflamed by seeing members of staff enjoying hot and cold drinks at the reception desks.”  and “Our priority must be to ensure that we are not compromising our high standards by presenting a poor impression to the public and staff who visit our departments.” But the thing is, people drink something on the go precisely because/when they are too busy to eat or take proper breaks. And it’s not always possible to drink fluids in a  space which isn’t exposed to patients; not every GP practice or ward has work spaces where staff can work out of sight of patients. And whilst there’s usually some kind of staff room somewhere, if you’re too busy to take a break then having a quick coffee at your desk whilst you type or between patients can make your life a lot less horrific. I feel that if a trust has lots of staff drinking hot drinks on the go in front of patients, that’s the symptom and not the problem; ensure adequate staffing levels so people can take breaks, and ensure there are plenty of spaces close by to their work environments that are out of sight of patients that they can take a break in or grab a quick drink in, and they won’t be drinking in front of patients. But I honestly don’t see why patients should be offended by a cup of tea on someone’s desk or at a reception desk, and I think that attitude arises from a misunderstanding of why people are drinking beverages in front of patients. Most people understand that staff are busy, and in reality having a quick coffee whilst you keep working is the literal opposite of lazing around at work; if you are seeing someone at a workstation, and they don’t even leave it to drink their beverage (which in all honesty is probably growing cold whilst they are working), it’s only construed as lazy if you inherently see inbibing fluid as a lazy activity, or believe that people at work should be working literally 100% of the time with no breaks. And although I try to avoid eating or drinking within eyesight of patients as much as possible; I avoid the hospital canteen wherever possible, to avoid running into them, lest spending my break catching up on news on my phone be misconstrued as ‘doctors being lazy’, I don’t believe encouraging this line of thinking is inherently correct. By bowing to these kinds of complaints rather than addressing the fact that the real issues are understaffing, delays in services or staff not being able to take adequate breaks, we’re encouraging the view that having a drink or taking a break is inherently lazy, and something that should be done with utter secrecy. Like it’s a weird secret. When, really, patients and visitors should be able to understand that staff are entitled to drink something or take a break. And that although things should be kept as professional as possible (and treating patients comes first), hytrating yourself shouldn’t be seen as inherently unprofessional.

Reblogging for the comments.

I volunteered to work as a nurse at EDC for the 3rd year in a row and honestly, it’s so cool. I learn so much by doing this field hospital stuff. And I got to be a charge nurse for the medical yellow tent this year, so that was really cool!

The future of medicine and emergency care. ❤💉😷

via BritishRedCross

New born ALS training with paediatric consultants! Brilliant chance to learn!

Watch: Kristen Bell opens up about the mental health double standard and how she manages her own struggle.

Follow @this-is-life-actually

Hit reblog on this so hard

SHOUT OUT TO KRISTEN BELL’S MOM THOUGH? WHAT KIND OF FANTASTIC SELF-AWARE PARENTING, WELL DONE MA'AM