Medical Daily

I’ve been unfortunate to have lost a few good stethoscopes the past year and each time I replaced them, I continued to buy cheaper ones. Sadly, I did notice a drop in quality with the products when I did this. Each time I went to a different brand and try to reason that it really didn’t matter what I got so long as it was useful to me.

Honestly, though, I found that Littman produces some of the best stethoscopes with a wide pricing range based on what you want to spend.

3M Littmann Lightweight II 

If you’re looking for something on the cheaper end, but still solid quality, I would always go with the 3M Littmann Lightweight II. It’s lightweight with a flexible hose. It’s fantastic when you’re trying to listen to lung sounds and you can get decent heart tones when necessary. The price is reasonable at less than $40.

You get what you pay for and this is no different with stethoscopes. While I love the  3M Littmann Classic II, I found it lacked a few qualities I needed when working in the emergency rooms or with a variety of patients. It only had the one large bell, which could get me generally sounds quickly, but the sound details weren’t of the highest quality. 

3M Littmann Classic III

The  3M Littmann Classic III has a higher quality sound though and has the class two bell system with it. I found it much more efficient when it came to listening to the ranges of high and low pitch sounds that couldn’t be heard in the  3M Littmann Classic II. Also, the clarity of the sound made easier for me to hear those heart tones that may or may not be an S3 or S4.

Another added benefit is with pediatric patients. The smaller bell always helps me gather clearer heart tones and lung sounds, without picking up the tiny adorable stethoscope they hide at the nursing stations in a draw so physicians don’t steal the only one they have. Ultimately the  3M Littmann Classic III is my #1 for affordable and highest quality.

3M Littmann 6163

This last Littman is by the best one I’ve probably every used in my career. The  3M Littmann 6163 Cardiology IV is $170, but it is worth every penny. Higher frequency sounds can be heard with as little as pushing a little hard against the patient's chest. It had a Dual-lumen tubing, which assisted in the rubbing noises we would hear in another stethoscope. It is made of lightweight material, but extremely durable to wear. 

If you’re the type of person that won’t let a single soul touch your stethoscope, or you feel like it won’t go missing, then I would invest the extra money on the 3M Littmann 6163 Cardiology IV. 

 For those of you that lose your stethoscope like me:

I was in the ER working when I noticed an RN had something attached to his stethoscope. It was a Tile Mate. One of those wifi assisted devices that help you find your car keys were attached to it with a simple zip tie. While it wouldn't entirely prevent theft, it does eliminate the guessing where you left it last.  

Why and How we use Ultrasound

For anyone that has worked in a hospital, ultrasound is a common tool of the trade. It is used for a variety of things:

Checking for pulses when palpation fails

Checking for fetal heart tones

Looking for occlusions in veins and arteries

Looking at the fetus as it grows

Checking the chest cavity 

And a lot more.

We all know WHAT it is, but we don’t really take the time to learn how it works or why we use it in the first place as one of our most common tools to assist in patient care. 

One Cool Usage of Ultrasound

In 2005, the  University of Heidelberg completed a study that used low-frequency ultrasound to help diagnose stroke in individuals with ischemia present and then treatment. The study is now publicly shared on the AHA stroke page.

Here are a few images show with the study:

Conclusion

This is a brief introduction to how ultrasound works and an interesting study using ultrasound as a tool to help diagnose strokes. This is only a sliver of the possibilities we can see with this technology.

Written by: MedDaily

I got a message to do some toxicology pieces and that kind of reminded me of something I saw over the weekend that I just HAD to research. It is a series of drugs that the news was calling 100 times more potent than heroin or fentanyl, but in reality, it just wasn’t a narcotic.

Warning, due to the limited information out on the drug and its actual effects on a human, I am going to have to go over the pharmacological results for the most part and what I’ve pondered about this drug. I also had to do a Wikipedia search, so not going to say it’s 100% accurate, but not terrible either.

W-18 and -15

The history

First off, these two drugs are being used as a heroin substitute by many addicts. The news has gotten ahead of itself and calling it a narcotic because it originally came from the 1980’s research for analgesic drugs at the University of Alberta. It was actually apart of a series of 32 drugs. The series would later become Schedule 1 narcotics, making them illegal to use in any situation.

Pharmacology

At UNC School of Medicine, a comprehensive pharmacological profile was made of the two major players for this heroine replacement. The major goal of this study was to determine, which receptors the chemicals would bind to, how it was metabolized in the body, and how long would they take to break down.

The most important discovery of this reacher determined that they have no opioid activity. The abstract alone stated:

“Although W-18 and W-15 have been described as having potent antinociceptive activity and are presumed to interact with opioid receptors, we found them to be without detectible opioid activity at µ, δ, κ and nociception opioid receptors in a variety of assays.” (source 2)

Later in the paper, it does state that can bind with weakly binding sigma receptors and some benzodiazepine receptors.

Finally, they found a weak adherence to the H3-histamine receptor, which can play a big role in cardiac function.

Metabolism is done majorly in the liver and there was no change in how where or how the drug affected the receptors after broken down by the liver enzymes.

Excretion is believed to follow common routes of urination at this time.

Personal thoughts

While there isn’t a lot of information, I can honestly say that this fake opioid will NOT work with a standard convention of Narcan, but with the weak affinity for peripheral benzo receptors, maybe a flumazenil may do the trick.

The H3-histamine receptor is another concern. If you find a patient taking this drug, you may find them going into some kind of dysrhythmia. The patient that I dealt with states to have had an allergic reaction, causing his lower extremities to swell up, but had a heart rate of 130 bpm and in a normal sinus rhythm at the time. The patient was hyperthermic and BP was holding up well. Pt was honestly stable, but his last usage was greater than 24 hours and he still had some symptoms. Pt was later admitted to observation to ensure the swelling returned to normal to watch for lab and cardiac changes.

Sources:

Pharmacology of W-18 and W-15 - UNC School of Medicine

Wiki

_________________

What is your opinion on this drug? Do you have experience with it or have you found additional research about it and its effects on human subjects?

There is quite a lot to be said about the medications we use for patients with arrhythmias. It’s easy to get lost as to what drugs do what and how, but thankfully there was a kind enough person by the name of Vaughan Williams, who actually broke them down into separate classes. Each class effects separate parts of the cardiac cycle, ultimately changing the electrical current of the heart.

Cardiac Action Potential

Before looking at the medications, we have to understand the cardiac cycle and how it actually works.

Source: x

The above chart presents the four phases of an action potential in a ventricular myocardial cell and how the electrolytes are used to cause the depolarization and repolarization of myocardial cells.

Phase 0  begins with a slight influx of sodium until it passes the potential threshold. Once past the threshold, more sodium channels will open and flood the cell, causing it the depolarize.

Phase 1 is an efflux of potassium from the cell, causing the cell to reach 0mV.

Phase 2 happens at this point. This is when calcium influx happens, prolonging the repolarization period. This period also goes by the name of an absolute refractory period for the cell, since it cannot depolarize during this time.

Phase 3 Calcium channels close again and potassium continues to efflux from the myocardial cell until the internal cell voltage returns to -90mV. Majority of potassium channels then close and the heart enters phase 4, which potassium is allowed to continue to leak into from the cell.

This process happens anywhere from 60 to 100 times per MINUTE!

Vaughan Williams Classifications

The major purpose of the medications in this class effect they way the cardiac action potential works in the cells of the heart. The drugs usually help to slow down specific phase to the heart and allow the heart to fix itself a bit.

Class I - Sodium Channel Blockers

These medications are designed to disrupt phase 0, causing a prolongation of it. There are 3 subcategories (a,b,c) that are broken down into moderate, weak, and strong.

This article won’t go into great depths, but the major goal of the class is to prolong the QRS complex and prolong or shorten QTi.

Medications include:

Lidocaine

Verapamil

Procainamide

Propafenone

Class II - Beta Blockers (-olol or -alol)

Quite commonly used out of hospital for patients with hypertension, beta blockers are actually a common antidysrhythmic. The basic pharmacology is: by blocking the beta-1 receptor sites, it prevents stimulation of the cardiac muscle to beat faster. The increase of sympathetic tone will decrease the rate the heart will beat.

Medications include:

Propranolol

Metoprolol

Carvedilol

Class III - Potassium Channel Blockers

Similar to the Class Ia medications, potassium channel blockers are used to prolong APD, which can cause a prolongation of ERP. This class of medication is commonly known to treat different ventricular dysrhythmias (Vtach or Vfib). The most common medication for this class is Amiodarone and deserves a post of its own.

It’s most common use is during CPR, when the patient is in pulses Vtach or Vfib rhythm and is then followed by a drip with ROSC is achieved. An important note to make about Amiodarone is it can take 16 weeks to leave the system.

Medications include:

Amiodarone

Sotalol 

Ibutilide

Class IV - Calcium Channel Blockers

Commonly uses for Afib with RVR and PSVT, a calcium channel blocker will prolong phase 2 of the action potion in the cell. The goal is to slow the conduction through the atrioventricular (AV) node, slowing the ventricular tachycardia that is occurring. By prolonging the ERP in the AV node, the heart is able to regulate the rate better.

Calcium channel blockers are commonly prescribed by physicians to assist in the care of such arrhythmias. One side effect of these drugs is it may drop the patient's BP, so ensure you have an SBP >100 or a MAP >65, prior to administering the medication

Class V - Others

This is the mix bag class. These drugs do not truly fit in any category but are still highly important to mention anyways. Two of these medications are Adenosine and Digoxin.

Adenosine prevents the re-entry of a signal in a sinus rhythm, preventing SVT. A warning though is for patients that have WPW syndrome may cause an increase in heart rate instead, so make sure you’re reading the rhythm correctly.

Digoxin effects vagal tone and is seen less as an emergency drug and more as a maintenance drug for chronic heart issues. A major issue with this drug is it holds a very narrow therapeutic index. Toxicity is quite possible if given too much.

Summary

Each class works in its own way on the action potential in the cardiac conduction system. How they affect the heart greatly determines when and how the medication should be used in different medical scenarios. The point of this article is to help a bit with the pharmacodynamics involved with the medications and to hint at the situations a person in the medical field would use them?

Remember to check out my facebook page. Feel free to send suggestions for possible article ideas, it might pop up some time. Always remember that medicine is an art, just as much as a science.

Hi all!

I have been working on this concept for a while now. I want to create not one application but a series of them. Each would be for the specific specialty of medicine and then another for community health. 

The Problem

I currently don’t have the time or training to create applications to their fullest potential.

The Opportunity

I am looking for people looking to create apps with some experience and want to take part this venture with me. The gig will be perfect for college students or people currently finishing up in a course on app development. 

The End Goal

This is not an upfront paying job. This is an opportunity to test your skills as an app developer and after completion receives a portion of the profits that are made if any are to be made.

Contact me if you are interested with your name, experience, and a little about yourself. I’m hoping to have at least 2-3 developers collaborating and at least 1 UX designer.

Alright guys and girls, let’s see how many errors we can spot with the medic working on this patient. If you’ve ever been a 68W, you’ve probably seen this video in training, so let’s see if you can remember you TCCC.

Toddler to Preschooler (1 year - 5 years)

We all know this age group when our young ones begin to learn to talk and feed themselves. They learn to use the potty and start making new friends. This is when they love the word, “No!” 

A lot of development occurs during this period of time and the growth in children, both mentally and physically are key. Here are some brief notes for you to look at for reference to what is to come with this age group:

Increase in illness, due to being around new children and playing with them.

Immune system will begin to grow in new environments

Neuromuscular growth occurs as they begin to develop finer motor skills

Brain will weigh 90% of an adult’s

Renal development is important as they begin to learn toilet training.

12 to 15 months feeling of fullness is known

18 months ability to control bladder muscles for excretions

Separation anxiety peeks 10 – 18 months

Basic language is mastered at 36 months

Age 3 – 4 most can understand full sentences.

Children begin learning sexual differences by observing their role models and siblings

Tip: do no try reason with children this age as to why a procedure needs to be done.

Newborn and Infants are 0 to 1 year of age.

From time of conception through the first year of life, infants change a lot. There are a few key psychological and physiologic changes to the human during this time.

In the first month, the newborn cannot rollover

Fontanels are present and can be a good sign dehydration or inflammation of the brain

Large head and short neck

Notable reflexes a newborn will have are:

Rooting reflex – The Baby’s cheek is stroked. Ensures the infant’s feeding will be a reflexive habit

Grasp reflex – An object is pressed into the palm of the baby. Helps in exploratory learning

 Moro reflex – Loud noises or a sudden drop in height while holding the baby. Protects from falling; could have assisted infants in holding onto their mothers during rough traveling.

Piaget’s Stages of Cognitive Development first state is Sensorimotor

Birth to ~2 years – primary senses seeing, hearing, touching, and tasting. How children learn about the world

Sources:

https://www.aagbi.org/sites/default/files/7-Paediatric-anatomy-physiology-and-the-basics-of-paediatric-anaesthesia.pdf

http://open.lib.umn.edu/intropsyc/chapter/6-2-infancy-and-childhood-exploring-and-learning/

Next will be the age group is Toddlers

For everyone entering or returning to school, welcome back and I am officially back!

What I am about to go over is basic stuff today, but it seems we all get a bit lax with and I feel review for us all is important at this time.

Patient assessment falls on the back steps at times. It is key for our jobs as medical professionals, but quickly forgotten when we use to our tools. We get tunnel vision at times and treat what we hear. This is true of EMTs, Nurses, PAs, NPs, MDs and any others.

Chest pain usually means the following things

Vitals

EKG

Labs

Chest X-ray

IV/IV fluids

Nitro

 ASA

We as providers are trained to think heart attack first. While it is good to put this in your differentials, it’s not always good to jump the gun to it either.

Doorway Impression

A doorway impression is simple that. When you walk in, what do you see?

If you’re in the hospital, how they got to their room, where they sit, how their physical appearance is can all be clues. While we shouldn’t judge, seeing an obese male in his 60’s with a pack of cigarettes in his pockets, you can probably put cardiac related issues in the “possible” pile.

If you see a 20-year-old college student who appears in shape that is curled up with his knees to his chest and taking rapid shallow breaths, your first opinion might not be cardiac, so it should shift in your list possible Dx.

That first impression won’t give tell you what it is most the time, but it might have a few clues.

ABC’s

If these weren’t pounded into your skull in medical school at any level, we need to chat later.

Airway, breathing and circulations are easy tools and tell you a lot. I will throw in their mental stats here as well.

If they are talking with you, their skin is warm dry and pink, and pulses are strong regular-regular radial; It’s safe to assume that they probably aren’t having a major issue at the moment. Their airway is patent, breathing appears unlabored and after some auscultation lungs to be clear to be sure. Strong pulses that are regular-regular is helpful. Skin condition tells you they’re probably not in shock.

You walk in to a patient that is pale, diaphoretic, barely able to get a few words out, before taking gasping breaths. That alone should tell you something is up. Airway may be patent, but breathing obviously isn’t good. Lung sounds might present with wheezing, which will give you the impression of allergic reaction or asthma attack. When do feel a pulse, is it bounding or stringy might give you a bit more information. This is all just from assessing their ABC’s.

Now, if they are not breathing and there is no pulse, for the love of god, start CPR!

Patient history

Time to get the story down. There is a lot to ask the patient, start with why they seek medical attention at this time. What is the chief complaint.

You’ll then go through you OPQRST and SAMPLE. Ask you these questions, you can add things that may assist in leading you toward what is going on with them. Remember not get tunnel vision when you find a single detail, but try having some solid follow up questions.

Tip: try to have the describe things. Don’t give them a lot of “yes” or “no” questions.

Vitals

Vitals can say a lot and pending where you work, they maybe be done early on in your assessment process and that is perfectly fine. They will play a role in determining if your patient is stable or unstable, but this can still determine early without vitals.

Testing

Now you can get their testing, but with it won’t be just chest pain now. You might be looking for an MI, but PE. There maybe be a bruise on that 20-year-old chest from when he got hit with a bat three days ago. You patient that came in with difficulty breathing might have a Hx of COPD and today just got worse.

Test should be done here to assist with further Dx of the pt. This is where you do your EKG, BG, X-rays, and everything else.

Final Notes

Diagnosing a patient is more than a few tests when related to a chief complaint. It is a series of steps that require you as health care provider to look at and break things down. The list above is not a steadfast list either, it is a general outline that we should all look at as the basics.

Ultimately, how you perform these steps pends on how you work and the way you develop your questioning habits. The major point of this is that we need to get past our labs, ekgs, x-rays, TCs and other toys. We need to look at the patient first and ask ourselves what are all the possibilities and then begin looking through out differentials and picking our exams from there.

Here is a nifty YouTube I stumbled upon for some down and dirty learning. It is some down and dirty, key facts to remember. If you’re looking for some quick review to get those neurons firing, this might be a good place to look.

Cons to this page is there are a limited number of videos to look through. I wouldn’t rely on them alone for studying and review, but just to get the big picture.

Look through the:

Rapid Sequence Intubation

Cardiology

Neurology