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Old 30-09-2010, 13:01   #46
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Originally Posted by Dockhead View Post
The protocol for an MI is to rush you to a cardiac center, just like in the US. The only difference is that they send special cardiac ambulances with real doctors, instead of paramedics. You'd still rather have your MI (god forbid) in the US, because the cardiac center, once you get there, is going to be better.
You should not slight paramedic care. In a a well designed EMS system, the presence of a physician on the ambulance attending a MI patient vs a paramedic makes little difference. In fact, our medical director even says that there is not a shred of evidence that suggests that there is better management of cardiac arrest in the emergency room, than on the ambulance; and all arrests are to be worked in the field.

Definitive treatment for a MI is in the cath lab... as long as you are kept alive long enough to see it!

NOTE: The above statement does not mean the writer suggests a paramedic is trained anywhere near to the level of a physician, but is rather a statement of the limitations of what can be done in the field by ANYONE! Which brings me back to my original post in this thread:
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Originally Posted by capngeo
The long and short of it is all the medical equipment in the world is of little use if you do not posses the knowledge necessary to use it!
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Old 30-09-2010, 13:04   #47
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Originally Posted by capngeo View Post
You should not slight paramedic care. In a a well designed EMS system, the presence of a physician on the ambulance attending a MI patient vs a paramedic makes little difference. In fact, our medical director even says that there is not a shred of evidence that suggests that there is better management of cardiac arrest in the emergency room, than on the ambulance; and all arrests are to be worked in the field.

Definitive treatment for a MI is in the cath lab... as long as you are kept alive long enough to see it!

NOTE: The above statement does not mean the writer suggests a paramedic is trained anywhere near to the level of a physician, but is rather a statement of the limitations of what can be done in the field by ANYONE! Which brings me back to my original post in this thread:
Thats right. I dont do anything in the ED that Paramedics don't do in the ambulance. They have the same equipment (functionally), the same drugs, the same physiology, use the same protocols.

And if they're paramedics I've trained or supervised, they know about the same too.
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Old 30-09-2010, 13:09   #48
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In many cases, I suspect that first aid might be administered by an expert first aider (like a paramedic) as well as might a typical (not ER) physician; just as an experienced phlebotomist might be better at drawing a blood sample than would a physician.
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Old 30-09-2010, 13:10   #49
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I'm (still) a reserve military officer, currently in the US Army Reserves as a medical officer (quite a letdown for a USAF fighter pilot.....). A great deal of my time as a physician in the Army is explaining to medics why their urban legends, conventional wisdom and 'thats what my Sergeant taught me at AIT' is a bad idea. For example, tampons are not good blood-stoppers, and if you're going to carry them why not carry the right stuff, that actually works, instead?

As far as people who were military medics, there has been a huge change in the training medics have received, even in the recent (last 5 year) past. Someone trained as a medic prior to Desert Storm? They'd lack even common EMT skills today. Just because someone is a medic doesn't mean they were any good at it, either: I prescribed hemorrhoid cream (Preparation-H) for one soldier (we were in the field at the time) and a 'medic' (a senior Non-commissioned Officer, an E-7 no less) gave him linament ointment (Ben-gay), and claimed 'they were the same thing'.

Not quite.

Many medics in the military, and in civilian life, are very anxious to get more knowledge and training. Unfortunately the training they receive is minimal at best (unless they are special forces medics), and so they go and try and find more knowledge on the internet. As do we all.

The problem with internet medical knowledge is that a) there's no validation of it, and b) knowledge thats out there may be horribly out of date, no matter how valid it might appear. There is a publication that has been floating around for at least 30 years now, purporting to be the "Green Berets Medic Handbook". It even has a number - ST-31-91B. Woo-hoo! It must be 'official'!

What it is is a reprint of the class handouts that Green Beret medics were given in the immediate post-Vietnam era, written by Green Beret medics, and based on pretty much old wives tails, folklore, and other less than stellar sources. Much of the advice in that book is nonsense, and the former Command Surgeon of the US Army Special Operations Command, had this to say about it:



Or worse, people will hear 'war stories' from people who may or may not be what they purport to be. The 'plug the hole with a tampon' story seems to have come from a science fiction writer, and has spread all over the EMS world - in and out of the military. But they'll all say that a buddy who was a (insert military force) (insert special operations team) medic told them they did it....

These days, we (military physicians) occasionally see things that just don't make any sense, performed by medics. OK, whatever. Most of the time it doesn't have any impact (good or bad) on the outcome: Those that would live still lived, those that unfortunately won't, don't, no matter what.

But, salt is bad for many reasons, as I indicated. For example, the sodium in salt (it's sodium and chloride ions in an octahedral molecular matrix) is very reactive - those ions will pop off the chloride ion and do something, with something else. Usually not a good thing in the body (sodium ions are used for LOTS of important things in the body, adding more of them willy-nilly is a bad idea). Dumping salt into a wound isnt going to have the same effect as (say) administering saline solution, either - the saline solution goes into the vasculature (plumbing), and has specific and not always benign results. Likewise the now free chloride ion is in the wrong place at the wrong time, and can cause trouble. Even if the ions bind to something innocuous, they are now not doing what they're supposed to and neither is that salt absorbing any water. It's just diminished.

The way that sugar, and honey, work as an antibacterial is by absorbing water from the bacterial cell, killing it. Cells are (kind of like) baggies full of wet stuff (cytosol) that has smaller parts floating around in it doing important (for the cell) things. In order for the organelle (the smaller part) to get whatever it needs into it, or move whatever it's doing out of it, the cytosol environment has to be correct: Making it much drier stops that from happening. Get the cell dry enough and the cell starves/suffocates, or crystals growing inside of it from the dehydration puncture the cell membrane, which lets wildly different pH components in to wreck havoc.

In practice, in treating wounds, the sugar or honey has to be replaced several times a day, after it's absorbed enough water to turn into a syrup. The patient also has to be well-hydrated as well.

The commercial products like quikclot, celox, or things like instant potatoes have the same effect: They cause the water (only) inside the blood sloshing around outside of the vasculature to be absorbed, which increases the concentration of the blood components including clotting factors. Its not perfect, but it's frankly better than most other things (including injecting clotting factors directly, it turns out).

The reasons that physicians usually don't have much patience for so-called alternative medical procedures (or techniques) is because they fail to have any plausible mode of working, based on the science that we (physicians) learn. Even before medical school we have to study general and organic chemistry, biology, physics, so that in classes like biochemistry or physiology we understand not only what is happening, but the basic scientific principals that MAKE them happen. If there is no plausible reason that something CAN happen, it probably doesn't and it takes more than urban legend to make it true.

And if you think that a mouldy cantalope is the same as a drug, try it yourself.

Now, I can't afford (as a physician) to spend the time to explain to each patient that comes in that what they heard from some dude who was a military medic is nonsense.
Fascinating and useful. Thanks for that. We are privileged indeed that you are willing to explain all this to us, in such lucid detail too, which you wouldn't have time to explain to every patient.
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Old 30-09-2010, 13:16   #50
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I think the med kit or contents you choose should be influence by:

1. Your ability to use alternatives

2. Your first aid knowledge

3. Your risk assessment of your crew on your cruise and how this fits into your overall budget and risk management agenda.

I think one size fits all mentality is likely cause a less than efficent decision.

Discussion:

1. If you feel capable of making splints, bandaging, etc. from other items you have on board, it may make sense to put your money and space into other items instead. Medications are hard to find substitutes for, so I place an emphasis there. Many posts here have given some great examples of things one can use to treat injuries that are not contained in a first aid kit.

2. It doesn't do you any good to bring items that are beyond your training and you will never use.

3. First Aid is only one part of overall risk managment. The needs will also vary with the crew and environmental conditions. Elderly people and those with pre-existing conditions present different risks that young, healthy people. Treatment preparedness should reflect such varying risks. It pays to have the supplies and training to deal with an emergency. It's better yet to prevent an emergency from occuring in the first place. Far too often I see wilderness travelers spend a great deal of time, effort and money on incident treatment while spending almost no time or resources on the indicident prevention which may avoid the incident all together.

This is in reference to first aid and risk management in general more than the sepcifics of passagemaking.
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Old 30-09-2010, 13:28   #51
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Quote:
Originally Posted by GordMay View Post
In many cases, I suspect that first aid might be administered by an expert first aider (like a paramedic) as well as might a typical (not ER) physician; just as an experienced phlebotomist might be better at drawing a blood sample than would a physician.
Some of the worst CPR I've ever seen done was by physicians and nurses (not Emergency physicians and nurses, of course). And keeping physicians current on technique has led to a series of 'merit badges' like ACLS and ATLS. You don't want a moonlighting psychiatrist dealing with your MI or trauma.

And you're right, I can draw blood from you but you probably wouldn't want me to
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Old 30-09-2010, 13:30   #52
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Fascinating and useful. Thanks for that. We are privileged indeed that you are willing to explain all this to us, in such lucid detail too, which you wouldn't have time to explain to every patient.
You're welcome.

As it happens I'm waiting here in our new townhouse in Canada, waiting for furniture to be delivered....so I have some time right now

I have to give props to Rogers (Cable/Internet/Phone) provider though, they showed up an hour early and got everything hooked up in short order.
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Old 30-09-2010, 13:34   #53
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This is, without any shadow of doubt the best forum I have read after weeks of lurking & bringing myself up to speed after a long layoff from sailing.

If I can add anything it is to reaffirm the bit about allergies, especially to antibiotics. I do not have any allergies that I know of (well, work is creeping in there). I had 2 kids who are allergic to penicillin which I found out the hard way.
If I had been miles off shore I would may have caused more problems. My daughter got an insignificant scratch not even noticed until hours later when a red streak was half way up her leg and she started to complain. We were still hours from any sort of hospital and also a Sunday. It took a few more hospital visits in different towns to find an antibiotic that worked. My point is, you should not leave port after treatment until your patient is on the mend.

Thanks for all your input

Mike
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Old 30-09-2010, 13:37   #54
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Originally Posted by nautical62 View Post
I think the med kit or contents you choose should be influence by:

1. Your ability to use alternatives

2. Your first aid knowledge

3. Your risk assessment of your crew on your cruise and how this fits into your overall budget and risk management agenda.

I think one size fits all mentality is likely cause a less than efficent decision.

Discussion:

1. If you feel capable of making splints, bandaging, etc. from other items you have on board, it may make sense to put your money and space into other items instead. Medications are hard to find substitutes for, so I place an emphasis there. Many posts here have given some great examples of things one can use to treat injuries that are not contained in a first aid kit.

2. It doesn't do you any good to bring items that are beyond your training and you will never use.

3. First Aid is only one part of overall risk managment. The needs will also vary with the crew and environmental conditions. Elderly people and those with pre-existing conditions present different risks that young, healthy people. Treatment preparedness should reflect such varying risks. It pays to have the supplies and training to deal with an emergency. It's better yet to prevent an emergency from occuring in the first place. Far too often I see wilderness travelers spend a great deal of time, effort and money on incident treatment while spending almost no time or resources on the indicident prevention which may avoid the incident all together.

This is in reference to first aid and risk management in general more than the sepcifics of passagemaking.

I agree that carrying much beyond what you know how to use is pointless.

I think that being able to improvise is important, just in case - but having purpose-made items is usually faster, safer, and more effective. Yes, you would probably saw up a hatch board to make a splint but then you're missing a hatch board and sawing it will take a bit of time. Or you can reach into your bag of tricks and grab a SAM splint.
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Old 30-09-2010, 14:29   #55
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Yes, you would probably saw up a hatch board to make a splint but then you're missing a hatch board and sawing it will take a bit of time. Or you can reach into your bag of tricks and grab a SAM splint.
Or a sail batten..... or a pillow.... or blanket rolled up...seat cushion, dingy paddle, boat hook....... you get the idea
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Old 30-09-2010, 14:34   #56
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I agree that carrying much beyond what you know how to use is pointless...
Sometimes, it pays to have the tools, for someone (else) who knows how, to use.
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Old 30-09-2010, 18:16   #57
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Fascinating and useful. Thanks for that. We are privileged indeed that you are willing to explain all this to us, in such lucid detail too, which you wouldn't have time to explain to every patient.
Hear Hear...
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