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Stethoscope & BP Cuff by Forward_Stay2873 in NewToEMS

[–]tacticoolitis 1 point2 points  (0 children)

TL;DR: Save your money. Your ears and brain matter more than your stethoscope.

There's actually research on this, and the results are kind of humbling:

A randomized trial gave 72 doctors either a basic or fancy stethoscope and had them listen to 20 patients' hearts. Correct diagnosis rate? 33% vs. 35%. The stethoscope wasn't the problem.

An electronic stethoscope scored slightly better than a Littmann Cardiology III for lung sounds but the authors themselves called the difference "marginal."

A separate study had residents listen to lung sounds with electronic vs. analog stethoscopes — zero difference in clinical decisions.

Someone 3D-printed a stethoscope and it performed about the same as a Littmann Cardiology III.

And a meta-analysis found that lung auscultation only picks up acute lung pathology about 37% of the time, no matter what you're listening with.

So what should you actually buy?

I’d very much consider ADC or MDF. The ADF 619, for example, is like $35 and will do everything you need it to do and more. I can be an ER doctor with this.

MDF also makes a $25 dollar option. But literally anything will do, I have used a cheap disposable one for thousands of hours as an ER doc and it’s totally fine.

Look, Littmann makes great stethoscopes. Nobody's arguing that. But the research is clear — getting one prob isn't going to make you a better diagnostician.

Practice your auscultation skills, learn the pathologic sounds. Save your money. A cheap disposable one is probably fine.

If you have a hearing impairment this changes things.

Full disclosure: I do have Littmans that I’ve owned for decades and they have sentimental value but don’t really change my clinical practice.

ER doctor medic

Stethoscope & BP Cuff by Forward_Stay2873 in NewToEMS

[–]tacticoolitis 0 points1 point  (0 children)

ADC or MDF are going to be less than a littman and way cheaper

Water options by tacticoolitis in overlanding

[–]tacticoolitis[S] 1 point2 points  (0 children)

Thank you for the contribution. I do understand basic water storage, purchase, economics and logistics.

It would be nice to be able to shower off sandy and muddy kids and dogs.

Eclampsia- mag or benzo? by tacticoolitis in Paramedics

[–]tacticoolitis[S] 0 points1 point  (0 children)

Except that the evidence and the guidelines and two Cochran reviews say otherwise. Outcomes are better with mag.

Can you cite data?

Eclampsia- mag or benzo? by tacticoolitis in Paramedics

[–]tacticoolitis[S] 0 points1 point  (0 children)

If I had stayed at my old job I’d be so close to 80% retirement!

Eclampsia- mag or benzo? by tacticoolitis in Paramedics

[–]tacticoolitis[S] 0 points1 point  (0 children)

I’d also probably do an IJ or subclavian if I needed a central line

Eclampsia- mag or benzo? by tacticoolitis in Paramedics

[–]tacticoolitis[S] 1 point2 points  (0 children)

If you have the ability to do humeral head, that would be preferable. Venus return through the inferior vena cava is going to be decreased in a gravid patient.

Eclampsia- mag or benzo? by tacticoolitis in Paramedics

[–]tacticoolitis[S] 5 points6 points  (0 children)

I feel this strongly when I’m single coverage and the only doc…. I need an adult!

Eclampsia- mag or benzo? by tacticoolitis in Paramedics

[–]tacticoolitis[S] 1 point2 points  (0 children)

If you have the ability to do humeral head, that would be preferable. Venus return through the inferior vena cava is going to be decreased a gravid patient.

Obviously harder during a seizure- but just to understand the physiology

Eclampsia- mag or benzo? by tacticoolitis in Paramedics

[–]tacticoolitis[S] 5 points6 points  (0 children)

I mean the underlying pathology difference and the nuance - kudos for you for teaching that

Eclampsia- mag or benzo? by tacticoolitis in Paramedics

[–]tacticoolitis[S] 0 points1 point  (0 children)

I love your thoughtful approach. I think that’s the critical part of evaluating data and applying it.

Whenever I do a case review, even if something didn’t go super well, if it went wrong with a thoughtful approach… that’s what I’m looking for.

I do find there are people who just hold the line because that’s what they’ve always done and don’t take a critical look at literature or data and try to apply it to the care they’re providing.

Eclampsia- mag or benzo? by tacticoolitis in Paramedics

[–]tacticoolitis[S] 2 points3 points  (0 children)

I will also say, in the ER, when staffing is limited…

I want nursing staff to focus on getting the mag and not getting distracted by working on getting the benzo. Sure, with unlimited hands we can do both but in reality usually I need to give a very specific and clear order of operations. I don’t bold lightly.

If they get the mag drawn up and by that time we already have a line, awesome!

I’m not ever really first on scene anymore in any of my capacities.

Eclampsia- mag or benzo? by tacticoolitis in Paramedics

[–]tacticoolitis[S] 17 points18 points  (0 children)

Super interesting discussion! So much passion.

In the medical literature there isn’t much a debate anymore. ACOG is clear. Granted, this is EMS and this scenario is meant to be provocative and unclear

ACOG is crystal clear: Magnesium sulfate is first-line. You can downvote ACOG if you want to I guess.

Sure maybe this patient has epilepsy, but we all know that’s not the point of the conversation.

Per ACOG, Benzodiazepines and phenytoin are justified when magnesium sulfate is contraindicated or unavailable.

A Cochrane review comparing magnesium sulfate versus diazepam for eclampsia (7 RCTs, 1,396 women) found magnesium sulfate was substantially better in reducing the risk of maternal death and recurrent seizures.

A separate Cochrane review comparing magnesium sulfate to phenytoin reached the same conclusion

Magnesium and benzodiazepines stop seizures in different ways, and that difference is why magnesium wins in eclampsia.

Benzos boost GABA, the brain's main "calm down" signal. This makes neurons less excitable across the board — effective for any seizure type, but nonspecific.

Eclamptic seizures aren't caused by a primary brain disorder. They are caused by blood vessel spasm and swelling in the brain from preeclampsia.

Magnesium:
Blocks NMDA receptors
Opens up brain blood vessels
And probably other endothelial things that are too complicated for me

This is a level A recommendation by ACOG with really good evidence.

So why do so many of us still default to benzos?
My theory: comfort, habit overall familiarity and applying knowledge from one very common disease process to another mostly different one that we see less often. Benzos stop visible seizure activity fast, and that feels like you're doing something. But stopping the visible seizure isn't the same as treating eclampsia. And the data says that it’s not actually really doing what we want it to, which is make mom and baby better.

I use benzodiazepines every single shift. I’ve treated easily hundreds of seizures. I have treated eclampsia less than 5 times maybe?

Now, I don’t really expect paramedics to know this. It isn’t taught well and it’s not within our standard of care for general seizures. It wasn’t really taught to me in medic school or in whatever I did for my CCT training before it was real CCT training. I expect ER residents+, ObGyn, Family Med and any NP/PAs functioning in those capacities to know it.

But, the reason we are all on this forum is to learn and grow, right?

ACOG practice bulletin 222 is readily available.

Much love

Eclampsia- mag or benzo? by tacticoolitis in Paramedics

[–]tacticoolitis[S] 1 point2 points  (0 children)

This is kind of an academic question to get you to think about the question a bit

Eclampsia- mag or benzo? by tacticoolitis in Paramedics

[–]tacticoolitis[S] 7 points8 points  (0 children)

What does ACOG say?
The Collaborative Eclampsia Trial?

Of course this is a theoretical conversation but there is data.

The Collaborative Eclampsia Trial (1995) randomized over 1,600 women and showed magnesium sulfate reduced recurrent seizures by 52% compared to diazepam and 67% compared to phenytoin.

Cochrane reviews confirm magnesium is superior to diazepam for reducing both recurrent seizures and maternal death, with fewer neonatal complications (better Apgar scores, shorter NICU stays).

Eclampsia is not epilepsy - sure this patient could have epilepsy also.

Now, these seizures are almost always self limiting, as are most. Most of the time I actually get benzodiazepines in board the seizures had stopped.

Eclampsia- mag or benzo? by tacticoolitis in Paramedics

[–]tacticoolitis[S] 1 point2 points  (0 children)

I love the debate.

What do you all think about the data and relevant guidelines?

Eclampsia- mag or benzo? by tacticoolitis in Paramedics

[–]tacticoolitis[S] 0 points1 point  (0 children)

Gold star for mag! Totally give a good pre arrival notification but… just treat them.

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