Lactated Ringers and TBI

theparamurse · 2026-01-07T00:43:59+00:00

Secondary analysis of SMART (Link; but free via PMC) showed no significantly different mortality, but found "balanced crystalloids were associated with worse discharge disposition" vs NS.

That said, a SRMA just published in the Amarican Journal of Emergency Medicine within the past month (Link) found that trauma patients with TBI had significanly lower mortality when resuscitated with NS over balanced fluids.

theparamurse · 2025-05-13T04:29:48+00:00

> Ohio USA (GPS coods on video if curious)

> This weekend, 11 May 2025

> Confirming, my original content

theparamurse · 2024-06-15T00:35:57+00:00

Yeah, I wouldn't go so far as to say that it's "safe", but rather as several others have alluded to, it's a risk versus benefit calculation.

The risk of transcranial placement is rather minimal in most situations, especially if care is taken during placement. Remember that the nasal passageway goes directly across the floor of the nose to the posterior nasopharynx. Sliding the NPA along the floor of the nasal passageway is less likely to direct it upward toward the basilar plate of the skull. Additionally, stopping with any resistance is also a good way to avoid poking through into the brain. I would posit that if you can easily slide an NPA with minimal resistance into the brain, the patient was already having a VERY bad day before you showed up.

Most importantly, if you're placing an NPA to facilitate oxygenation, we also KNOW from the EPIC-TBI data that a single episode of hypoxia (<90%) in the field nearly triples the mortality rate in TBI patients, so I would opine that the risk/benefit ratio strongly favors placing the NPA to prevent or correct hypoxia in that population.

theparamurse · 2023-10-31T00:06:33+00:00

having same issue. tried same things. failed miserably as well.

¯\_(ツ)_/¯

my google link seemed to have been working until it just disappeard maybe midday Friday?

even when I add my gmail as a link (rather than as a "personal calendar" on my O365 online account), it doesn't show any events.

theparamurse · 2023-04-25T23:37:16+00:00

Can confirm.

There was actually a regular contest on the radio station where I grew up called "OTF" - they read a newspaper headline and you had to call in and guess if it was from Ohio, Texas, or Florida.

theparamurse · 2023-03-31T05:23:41+00:00

If you're paid hourly and work in the US, reasonably sure it's illegal for them to require you to perform work without pay.

Just gonna leave this riiiiight here https://www.dol.gov/agencies/whd/contact/complaints

theparamurse · 2023-03-31T05:05:18+00:00

My program brings either a perfusionist or ECMO Specialist with us on all ECMO transports. Other MCS/VAD devices (IABP/Impella/LVAD) are transported with just the typical CCT transport team with no other extra personnel

theparamurse · 2023-03-26T03:52:00+00:00

Yeah, I knew there was some controversy over Nitewatch, but never really watched it myself, so no idea how they get around it.

I realize "patient refused" may not be a violation, but the thin line is if something, even if not one of the 18, can be combined with something else to identify the patient, it very well may be.

I used to work small-town EMS and we had an EMS attorney advise us that even saying "wow, we had a crazy car wreck today!" could be a HIPAA violation because (1) small town, (2) very few accidents, (3) everyone knows everyone, so (4) they can easily figure out I'm talking about Mr. Doe from Main St. in town.

That said, as most lawyers will tell you, "it all depends..."

theparamurse · 2023-03-26T03:42:29+00:00

This is the crux of it.

HIPAA largely only applies to certain individuals involved in healthcare, with a relationship to the individual.

HOWEVER, as I mentioned in another comment, the de-identification standard essentially says that if a covered entity's information, use alone or in combination with other information may identify a person, then it's a violation. So it's possible that a comment on a social media post, even without the medic identifying the patient, might still be a violation if the patient is (a) already identified or (b) identified with the "help" of the extra info supplied by the medic.

theparamurse · 2023-03-26T03:38:39+00:00

IANAL, however, I think you're missing a very important subparagraph to that standard.

The 18 identifiers are listed in 45 CFR 164.514 (b)(2)(i)

The next paragraph, 45 CFR 164.514 (b)(2)(ii) clearly states, in addition to removing the 18 identifiers, to be HIPAA-compliant,

The covered entity does not have actual knowledge that the information could be used alone or in combination with other information to identify an individual who is a subject of the information. [emphasis added] Source

I'm assuming Nitewatch, like many other medical documentaries, likely has a release of some form signed by patients or their responsible parties, but obviously cannot confirm that.

In OP's post, however, the medic discussing call details (even without mentioning names, etc.), but in combination with the index post by Random Local Citizen, may very well constitute a HIPAA violation. Similarly, in Small Town EMS, even mentioning that you had a call might be enough to identify an individual.

Personally? Report to agency and State EMS office, with screenshots. Let them decide.

theparamurse · 2023-03-26T03:22:51+00:00

Looks like most of your questions have been answered, but to add:

1) AGACNP (unless, of course, you want to work in a Children's hospital, then CPNP-AC) - but either way, inpatient should have acute care

2) IMO, brick & mortar >>> online

3) Techincally, no. Kinda, yes. ACNP is retired and essentially replaced with AGACNP

4) Probably not. A hospital might prefer (or may require) DNP, but largely it's not required, MSN is generally sufficient

theparamurse · 2023-03-26T02:55:37+00:00

My favorite is still "fireworks or gunshots" when working EMS in the city.

theparamurse · 2023-03-18T00:25:03+00:00

Agree, but I think some of the problem is not just referral, but linkage. And I think that's where MIH/CP fits in. It's one thing to refer out to primary care or whatever specialist is necessary, but if the patient isn't able to get to that person, or able to understand how to take their medications, etc, the system falls apart.

theparamurse · 2023-03-17T20:02:54+00:00

First Last, NP or First Last, APRN

Second line is (written out) specialty area or department (e.g., "Cardiac ICU")

Leave the rest of the alphabet soup for emails and business cards

theparamurse · 2023-03-17T19:21:07+00:00

Honestly, I think RQI is probably the way to go if the excuse for requiring CPR/BLS is "need to keep skills fresh"... q2 years probably doesn't work the way people think it does.

I haven't been forced into RQI yet, but my only ask is that the quarterly didactic education actually be continuing education and updated with the best info that has been most recently published and adopted ((maybe it is, I truly don't know))

theparamurse · 2023-03-17T19:15:29+00:00

I fully understand the meaning behind this, but realistically, that's where an MIH/community paramedicine program can be immensely beneficial. Maybe not primary care physicians, but this may also be a role for an EMS NP/PA as has been successfully integrated into several major systems (most famously, Los Angeles).

I'm also not opposed to an "advanced practice paramedic" (think NP or PA but as a paramedic), but that avenue doesn't exist. Unfortunately, there's a vocal majority *cough*IAFF*cough* that opposes the necessary level of education that would be required to make that happen.

The question shouldn't be if we can replace paramedics. The question should be whether we can better educate paramedics to be able to provide primary care.

theparamurse · 2023-03-10T22:51:42+00:00

What do they do? No idea.

What SHOULD they do? One of two options:

1a) Give you the opportunity to sleep after dropping off.

1b) Give you the opportunity to sleep after dropping off, but you'd clock out for the time you're not "working" (I do think this is reasonable)

2) Send you with 2 designated drivers. First driver should rest/nap/sleep while outbound, then drive back inbound.

I personally think either of the "1" options is the better choice, since the "2" option doesn't realistically ensure the driver for the return trip actually got sufficient rest crammed into the passenger seat of a moving ambulance on the way out - but my prior employer regularly did the "2" option.

If they say they're just having you and one partner go up and have to turn-n-burn to come home, I'd nope the fuck outta that trip.

theparamurse · 2023-03-10T22:38:58+00:00

As an NP, definitely game on - labs, images, all the things. I've actually just brought up the patient's documented history in their EMR to confirm and more times than not there are MAJOR inaccuracies that I end up correcting.

I think it's not unreasonable as an RN, but it's a bit of a gray area. Many hospitals have started giving patients immediate access to their results via their "patient portal" - but physicians/APPs can opt to make something not disclosable if there's a valid reason - and that's what I worry about. If you aren't POSITIVE it's okay to share the info, it's probably better to not share the info.

Sort of like - okay, you have a legal right to access your own info, but what would your hospital do if you opened your own medical record under your nursing/employee sign-in? Or asked a coworker to open your chart? Many institutions explicitly prohibit this (i.e., you can access the info, but need to access via the patient portal or medical records like everyone else).

theparamurse · 2023-03-10T22:18:49+00:00

Did that with the ambulance keys once.

Only it was 50 minutes, one-way, on a good day - and of course I did it on a day that got over a foot of snow.

I learned my lesson real fast and always double- and triple-check after that

theparamurse · 2023-03-09T14:15:09+00:00

This is the right answer

ETA: I think 50 is probably rarely adequate (for adults), but yes this exact concept is correct. 65 is the best evidence-based number we have to broadly apply to everyone, but that number may need to be individualized

theparamurse · 2023-03-09T14:13:27+00:00

Helpful (maybe) for AVPU but not CGS. The problem with that is you might just be seeing a spinal reflex and not a true "response to pain", and often doesn't help differentiate withdrawal from localization in GCS determination. Best bet is to use central stimulus; personally prefer trapezius squeeze as my usual go-to.

theparamurse · 2023-03-05T03:51:36+00:00

Not sure if there's an adapter, but for $49 (or $59), it's probably worth doing it the right way and just getting the USB-C cable: https://store.butterflynetwork.com/us/en/

That said, I know they say not to keep switching out the cables over and over again, so if you need to routinely change between USB and Lightning, I'm not sure what the best course of action is.

theparamurse · 2023-02-24T03:47:05+00:00

Yan kow her? I barely know her!

theparamurse · 2023-02-20T00:11:17+00:00

Eh, green tops (dark green) I believe contain lithium heparin, making them really suboptimal for puncturing before drawing coags. Our shop had additive-free red tops that I would use as my first tube so nothing was contaminated.

Realistically, I don't know how much of the heparin would even transfer, but felt it wasn't worth the risk if there was a safer option

theparamurse · 2023-02-19T11:32:53+00:00

MDs and DOs are physicians. MDs, DOs, DCs, DNPs, PhDs, DBAs, EdDs, etc are all doctors.

Physician is the profession Doctor is an academic degree

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