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Medical emergencies.
Emergency Medical Services
What should the state governor and emergency medical services executives know about medical emergencies inside and outside the state?
  1. Annotation or definition.

  2. Annotation or definition of Emergency Medical Services.

  3. Analysis of complaints, incidents, issues, and problems

  4. Ambulance types for medical emergencies on the road.

  5. Addresses of emergency medical services in the state.

  6. Assessment of a patient in medical emergency by an emergency medicine specialist

  7. Blood Alcohol Concentration (BAC)

  8. Cardiopulmonary Resuscitation (CPR)

  9. Crash Cart Supply & Equipment Checklist

  10. Criteria for emergency medical services

  11. Critical and noncritical medical emergency

  12. Criteria for discharge from medical emergency room

  13. Critical care unit.

  14. Duties of the director of emergency medical services in the state.

  15. Difference between an emergency room physician and physician at other locations.

  16. Emergency medical room diagnosis and treatment.

  17. Emergency medical room diagnosis and treatment with surgical emergencies’ diagnosis and treatment.

  18. Emergency medical record printing. Emergency Medicine Specialist Training Programs

  19. Examples of emergency medical diagnosis and treatment

  20. Examples of emergency symptoms, signs, and complaints

  21. Equipment relevant to medical emergency

  22. Emergency medical record

  23. Emergency medications

  24. EMS education coordinator program

  25. Emergency Medicine Procedures

  26. Emergency medical services (EMS) systems act.

  27. Essential services maintenance act.

  28. Evaluation of a patient in an emergency room by emergency room physician.

  29. Emergency Patient Assessment

  30. Evaluation of a patient on the spot by an emergency medical responder, a physician.

  31. Emergency room physician telephone conversation.

  32. Eye Conditions

  33. Facts from every medical emergency room inside or outside the state that must be displayed via the Internet.

  34. Glasgow Coma Scale

  35. Human Vital Signs

  36. Human healthcare issues requiring on-the-spot diagnosis and treatment.

  37. Importance of www.qureshiuniversity.com/medicalemergency.html in emergency medical services.

  38. ICU Medical Conditions

  39. Intravenous fluids

  40. Inspections of all emergency medical equipment and supplies

  41. Locations and number of medical emergency rooms in every state.

  42. License status

  43. Life support

  44. Listing of emergency medical rooms in the state and intensive care units in the state.

  45. Medically related educational programs

  46. Medical accountability of the EMS

  47. Mass casualty units

  48. Occupations relevant to this department in the state.

  49. On-the-spot emergency medical diagnosis and treatment

  50. Pediatric Basic and Advanced Life Support

  51. Portable electro-cardiac monitor and defibrillators

  52. Preventve maintenance on all vital medical equipment

  53. Questions medical emergency room physicians must answer ahead of time.

  54. Reversible Causes of Cardiac Arrest: H's and T's

  55. Survival needs monitoring

  56. Symptoms, signs of medical emergencies.

  57. Surgical Skills

  58. Telephone assessment by emergency medicine specialist (dispatcher)

  59. Types of ambulances (Road)

  60. Urine Drug Test

Annotation or definition of Emergency Medical Services.
What are Emergency Medical Services in the state or outside the state?

Why was there a need to explain definition of Emergency Medical Services in the state or outside the state?
Some consider emergency medical services as providing out-of-hospital acute medical care.
Emergency medical services are out-of-hospital on the spot, on the spot to medical emergency room, in medical emergency room, in an operating room or in an intensive care unit.

How many emergency medical complaints are there?
161

What is a medical emergency?
If a human being has any problem, symptom, complaint, or situation listed below, it is a medical emergency.
http://www.qureshiuniversity.com/medicalemergency.html

How many critical medical complaints are there?
27

What are the critical medical complaints?
http://www.qureshiuniversity.org/criticalcareworld.html#Assessment of a patient by a physician.

How many human healthcare issues need on-the-spot diagnosis and treatment?
8

What human healthcare issues need on-the-spot diagnosis and treatment?
USTBDSSM(8) is the abbreviation.
1. Unconsciousness at a public place
2. Sudden unconsciousness at home
3. Trauma of various types
4. Burns
5. Drowning
6. Seizures
7. Survival needs issues of a person
8. Medico-legal cases with criminal activities, including women’s pregnancy issues


What medical emergency cases go to an emergency surgeon or emergency anesthetist in a hospital operating room?
Out of 1,150 human medical emergencies, only 27 go to an emergency surgeon and/or an emergency anesthetist in operating room.

What are examples of emergency cases that go to an emergency surgeon and/or emergency anesthetist in a hospital operating room?
http://www.qureshiuniversity.org/emergencymedicalservices.html#Emergency Surgeon and Emergency anesthetist

What is the deprivation of human survival needs (not having human survival needs)?
What are basic/normal human survival needs?
http://www.qureshiuniversity.org/survivalneeds.html

How many human medical emergencies are there?
There are fewer than 1,096 human medical emergencies.
If you know the human medical conditions, then you will be able to diagnose and treat them.

What are the medical emergencies in alphabetical order?
What are the medical emergencies as per medical specialty?

http://www.qureshiuniversity.org/emergencymedicinediagnosistreatment.html

How many human medical conditions are there?
There are more than 7,943 human medical conditions.

What are the medical conditions in alphabetical order?
Here are further guidelines.

What best describes the problem, symptom, complaint, or situation in the list?

_________________________

What type of assessment does this patient need?

_________________________

What will happen if this medical condition is left without treatment?

_________________________

The individual can die.
The individual can have a disability.
The individual can have severe pain.
The individual can have irreparable harm.

Does this situation need a doctor?

_________________________

What should be displayed on an emergency medical record?
Details of the patient.
Details of the diagnosing and treating medical doctor.


Details of the patient.

What should be your first question in case a patient is referred to you?

Patient 60-second assessment by call center/Internet/telemedicine.

Where is the patient now?

_________________________

How old is the patient?

_________________________

What is the gender of the patient?

_________________________

Who is reporting this emergency?

_________________________

What are the sources of medical history?

_________________________

Patient.
Family.
Patient not responding to medical history questions.
Community member.
Police officer.
Referral from medical doctor.
Other.

How much time has elapsed from the start of the emergency until now?

_________________________

Does one individual or many individuals have medical emergencies at this location?

_________________________

How many individuals have medical emergencies at this location?

_________________________

A medical emergency with an individual victim.
A multiple casualty incident.
Do you think this is a multiple causality incident?
If it is a multiple causality incident, the guidelines are different.

What are the types of patient assessment?
Patient 60-second assessment by call center/Internet/telemedicine.
Patient 60-second on-the-spot diagnosis and treatment.
Patient 60-second assessment in trauma.
Patient 10-minutes assessment in a medical emergency room.
Patient-focused history and physical exam.
Comprehensive patient assessment.


Check vital signs, mobility, and survival needs.

Consciousness of a human being has to be included in vital signs.

Vital Signs

Consciousness, pulse, blood pressure, respiratory rate, temperature.

Consciousness is extremely essential in reaching a correct diagnosis and treatment.

What are the vital signs on the date and time of diagnosis and treatment?

Date: Time: Consciousness: Pulse: Blood pressure: Respiratory rate: Temperature:
______ ______ ______ ______ ______ ______ ______
______ ______ ______ ______ ______ ______ ______
______ ______ ______ ______ ______ ______ ______

How do you categorize the condition of the patient?

_________________________

Undetermined
Good
Fair
Serious
Critical

Is this an emergency?

_________________________

What is the category of this emergency?

_________________________

Is this a medical emergency?

_________________________

In what type of setting does this patient need treatment?

_________________________
Here are various examples.
Critical care
Coroner investigations
Emergency room health care
Emergency call center
Hospital ward
Home health care
Internet human health care services
Labor, delivery, and recovery rooms
Medicolegal cases
On-the-spot diagnosis and treatment
Operating rooms
Other


Who has the duty to manage this emergency?

_________________________

What best describes this human emergency?

_________________________

Medical emergency
Surgical emergency
Trauma emergency
Pediatric emergency
Obstetrical/gynecological emergency
Medico legal case
Patient assessment
Patient 60-second on-the-spot diagnosis and treatment.

What problems, complaints, incidents, and issues need on-the-spot diagnosis and treatment?
Unconsciousness at a public location.
Sudden unconsciousness at home.
Trauma
Survival Needs
Seizures
Burns
Drowning
Human Pregnancy Emergencies
Here are further guidelines.
What is the reason for consultation?

_________________________

What seems to be the problem?

_________________________

How much time has elapsed from the start of the emergency until now?

_________________________

Does one individual or many individuals have medical emergencies at this location?

_________________________

How many individuals have medical emergencies at this location?

_________________________

What best describes your problem?

_________________________

Patient Name:________________________

Referred by:_________________________

Mailing Address:_____________________

Telephone:___________________________

Your Email Address:__________________

Date of Birth:_______________________

Gender: Male Female

Primary Care Physician Name, Address and Phone:__________________

Emergency Contact Name:______________

Relationship:________________________

Phone:_______________________________

Your Height:_________________________

Your Weight:_________________________

Race::_______________________________

White
Black/African American
Hispanic/Latino
Pacific Islander
Asian
Asian/American

Conscious

Can the patient talk?
Can the patient respond to verbal questions accurately?
Can the patient do spontaneous eye opening?
Does the patient respond to painful stimulus?
Is the patient conscious, oriented in time, space, and person?
Conscious means able to see, hear, and talk.
In pediatric patients younger than six months of age, the ability to make any verbal noise or cry is equivalent to talking.

What is the location of patient at the point of the medical emergency?
Can the patient talk relevant to age?
Can the patient walk relevant to age?
Are consciousness, pulse, blood pressure, and respiratory rate normal relevant to age?
What is the cause of the existing emergency medical scenario?

Here are further guidelines.

Here are further guidelines.

Emergency medical history

What questions should you ask in emergency medical history?
http://www.qureshiuniversity.com/medicalhistory.html

http://www.qureshiuniversity.com/vitals.html
Mobility
Survival Needs
Details of the diagnosing and treating medical doctor.

What is the name, date of birth, phone number, and other contact information of the person diagnosing and treating this patient?

_____________________________________________

What is the date and time you are diagnosing and treating this patient?

_____________________________________________

What is the location of the patient at the time you are diagnosing and treating this patient?

_____________________________________________

What best describes the location of diagnosis and treatment of this case?
1. On-the-spot diagnosis and treatment.
2. Emergency room diagnosis and treatment.
3. In the hospital diagnosis and treatment.
4. Long-distance health care advice.
5. Other
_____________________________________________
Can you reach a correct diagnosis and treatment of a human being?

_____________________________________________

What is the diagnosis of this patient?

_____________________________________________

How did your reach this diagnosis?

_____________________________________________

What is the treatment for this patient?

_____________________________________________

Does the patient need to be transferred to a medical emergency room?

_____________________________________________

In America up to February 12, 2012, most emergency medical records did not have these facts.

In what emergency medical category do you fit the condition of the patient you are diagnosing and treating on this date and time?

Undetermined, Good, Fair, Serious, Critical.

If on-the-spot diagnosis of a patient declared in serious or critical condition, arrange a bed in the Intensive Care unit.

Date of Examination:_________________________

Physician Name:_________________________

Physician Address:_________________________

Is it a Medical Emergency?

___________________________

In what type of setting does this patient need treatment?

___________________________

Do any recent causes lead to this problem; for example, trauma, missed medication, inadequate survival needs, stress, or other issue?

___________________________

What are further details?

___________________________

Does any past medical history lead to this problem?

___________________________

Is there any recent history within past few minutes or hours of any of the following:
1.Unconsciousness at a public location.
2.Sudden unconsciousness at home.
3.Trauma.
4.Survival needs issues.
5.Seizures.
6.Burns.
7.Drowning.


___________________________

If there is even one recent history of the above, on the spot diagnosis and treatment is required.

Is the victim's condition life or limb threatening?

___________________________

Could the victim's condition worsen and become life or limb-threatening on the way to the hospital?

___________________________

Could moving the victim cause further injury?

___________________________

Does the victim need the skills or equipment of paramedics or emergency medical technicians?

___________________________

Would distance or traffic conditions cause a delay in getting the victim to the hospital?

___________________________

What have been his activities for the last 10 years?

___________________________

Does the individual use or abuse any of these substances?
Alcohol.
Drugs.
Tobacco.

___________________________

Is the individual on any medication?

___________________________

Questions doctor on duty needs to answer.

Is it a medical emergency?

___________________________

What is the diagnosis?

___________________________

In what setting/location does this medical condition need treatment?
Treatment required on the spot.
Treatment required in the medical emergency room.
Treatment required in the intensive care unit.
Treatment required in the ward.
Treatment required in the operating room.
Treatment required at home.
Treatment required Internet health care.
Treatment required in OPD consultation.

___________________________

What treatment do you recommend for this patient?

___________________________

What are other treatment options for this patient?
No other treatment option.
Other treatment options are enumerated.

___________________________

Prescription
How do you do a quick assessment, diagnosis, and treatment of a conscious patient?
Are you the person reporting a medical emergency for yourself?
Emergency
How do you do a quick assessment, diagnosis, and treatment of an unconscious patient?
Are all vital signs normal? Can the person move relevant to age? Has the person been provided with survival resources? Does the person or caregiver complaint of anything? Are these justified complaints?

Addresses of emergency medical services in the state.
Why are the addresses of emergency medical services in the state essential? A physician/medical emergency responder with an ambulance is not available for an on-the-spot medical emergency. Addresses of emergency medical services in the state must be available to forward such a complaint.

Emergency medical room diagnoses in surgical emergencies.
What are emergency medical room diagnoses are also surgical emergencies and need treatment?
Here are further facts.
February 1, 2016
Surgical Emergencies
Recommendations relevant to hospitals and types of physicians inside and outside the state.
Who are these recommendations for?
Physician medical emergency staff, including heads of departments, seniors, juniors, and medical students.
Physician surgical medical emergency staff, including heads of departments, seniors, juniors, and medical students.
Physician surgical elective surgery staff, including heads of departments, seniors, juniors, and medical students.
Heads of various departments inside and outside the state.
Others.

Doctor Asif Qureshi, founder of Qureshi University, the Global Democratic Party, and the founder of United Continents of the World and United States of the World, forwards these recommendations dated February 1, 2016, from Chicago, Illinois, North America.

I am Doctor Asif Qureshi.
My biodata or profile is displayed at the resource displayed below.
http://www.qureshiuniversity.com/aboutthefounder.html
This is for those who need to know my biodata or profile.
I practiced as a physician medical emergency staff from March 5, 1995 to June 1998 at King Fahed Hospital in Medina.
On February 1, 2016, I was at my home office at 5042 N Winthrop Ave #237 in Chicago, Illinois, North America, and I came across the King Fahed Hospital Medina Orthopedic Department’s staff.

Take a look at this: http://www.madinaortho.com/staff/staff.htm

What are the actual categories required of surgeons?
Physician surgeon, medical emergency staff, (seniority: guide, heads of departments, consultants, seniors, juniors, and medical students)
Physician surgeon, elective surgery staff (seniority: guide, heads of departments, consultants, seniors, juniors, and medical students)

What is the actual entity for medical emergencies related to surgery?
Physician surgeon medical emergency
Seniority: head of the department of emergency surgery, consultant emergency surgery, senior emergency surgeon, junior surgeon of emergency surgery, and medical student.

How does a medical emergency in a hospital function?
Physician diagnoses a medical emergency and makes treatment recommendations.
A physician in a medical emergency makes treatment recommendations for emergency surgery consultation.
A physician surgeon in a medical emergency goes ahead with an emergency surgical consultation.

There are 14 different categories of surgical emergencies.
Is it possible to have 14 different categories of surgeons next to a physician in a medical emergency to deal with emergency surgical consultations?

No.

A physician surgeon in a medical emergency has to do all of the emergency surgical consultation. A physician surgeon in a medical emergency can be a guide, head of a department, a consultant, a senior, a junior, or a medical student.
What did you understand?


What is the role of Doctor Asif Qureshi in this situation?
A guide to all of them.

What can be the seniority of a physician surgeon in a medical emergency?
Head of the department physician surgeon in a medical emergency.
Consultant physician surgeon in a medical emergency.
Senior physician surgeon in a medical emergency.
Junior physician surgeon in a medical emergency.
Medical student physician surgeon in a medical emergency.

If any of you have had an orientation only to orthopedic surgical emergencies, you have to slowly get oriented to all surgical emergencies relevant to medical emergencies.

Examples of surgical emergencies.

Most common to least common medical conditions have been elaborated.

What are examples of all surgical emergencies?

1. General surgery emergencies

What are examples of general surgery emergencies?
Acute appendicitis
Acute pancreatitis
Biliary colic and cholecystitis
Massive upper GI bleeding
Peritonitis
Small bowel obstruction
Perforated abdominal viscus
Acute diverticulitis
Rectal bleeding
Acute abdomen that needs further diagnosis and treatment

2. Thoracic surgery emergencies

What are examples of thoracic surgical emergencies?
Airway obstruction
Tension pneumothorax
Massive haemothorax
Open pneumothorax
Flail chest segment with pulmonary contusion
Cardiac tamponade

3. Colon and rectal surgical emergencies

What are examples of colon and rectal surgical emergencies?
Injury to the colon and rectum (stab wound)
Hemorrhoids with unstoppable bleeding or severe pain
Fissures (painful tears in the anal lining)
Abscesses and fistulas (infections located around the anus and rectum)
Hemorrhage of rectum and anus
Anal incontinence
Anal sphincter repair
Rectal prolapse

4. Obstetrical emergencies

What are examples of Obstetrics emergencies?
Preterm labor and delivery
Premature rupture of membranes
Severe preeclampsia
Prolapsed umbilical cord
Antepartum hemorrhage
Ectopic pregnancy with shock
Acute abdominal pain during pregnancy
Abortion with hemorrhagic shock
Disseminated intravascular coagulation
Shoulder dystocia
Retained placenta
Abdominal pregnancy
Trauma during pregnancy
Cesarean section under general anesthesia
Cesarean section under local anesthesia
Cesarean section without anesthesia
Postmortem cesarean section
Cardiopulmonary resuscitation during pregnancy
Eclampsia
Abruption of the placenta
Placenta praevia
Postpartum hemorrhage
Amniotic fluid embolism
Inversion of uterus
Stillbirth and intrauterine death
Postpartum blues, puerpural depression, puerpural psychosis
Threatened abortion
Incomplete abortion
Complete abortion
Inevitable abortion
Septic abortion
Second trimester abortion
Third trimester delivery complication cesarean section
Third trimester delivery complication manual removal of the placenta
Third trimester delivery complication immediate post-partum hemorrhage
Post-partum hysterectomy (see criminal matters with hysterectomy)
Unruptured ectopic pregnancy
Ruptured ectopic pregnancy
Ovarian cyst, ruptured ovarian cyst
Ovarian cyst, unruptured ovarian cyst
Ovarian cyst, torsioned ovarian cyst
Pelvic inflammatory disease mild
Pelvic inflammatory disease moderate to severe
Pelvic inflammatory disease tubo-ovarian abscess
Abnormal vaginal bleeding

5. Gynecologic surgical emergencies

What are examples of gynecologic surgical emergencies?
Tubo-ovarian abscess
Hemorrhagic ovarian cysts
Gynecologic hemorrhage
Vulvovaginal trauma
Ectopic pregnancies
Adnexal torsion

6. Neurological surgical emergencies

What are examples of neurological surgical emergencies?
Subarachnoid hemorrhage
Intracranial hemorrhage
Brain AVM (arteriovenous malformation)
Spine fracture
Cauda equina
Penetrating injury
Intracranial lesions–focal
Open skull fracture
Head trauma
Cushing response
Epidural hematomas
Epidural hemorrhage
Uncal herniation
Pituitary adenoma
Pituitary apoplexy
Traumatic compression fracture
Jumped facets
Ballistic trauma or gunshot wound (GSW)
Shunt malfunction
T7-8 corpectomy and T6-T9 fusion
Cord compression
Clinical signs of high ICP

7. Ophthalmic surgical emergencies

What are examples of ophthalmic surgical emergencies?
Cataract surgery
Retinal procedures
Glaucoma
Strabismus
Corneal and oculo-plastic surgeries

8. Oral and maxillofacial surgical emergencies

What are examples of oral and maxillofacial surgical emergencies?
Dental extractions, including wisdom teeth
Dental implants and bone grafting
TMJ evaluations and management
Corrective jaw surgery
Facial infection treatment
Treatment of facial trauma
General oral surgery
Cosmetherapy, including botox, juvederm, and restylane

9. Orthopaedic surgical emergencies

What are examples of orthopaedic surgical emergencies?

Pediatric patients
Fractures.
Supracondylar humeral, femoral, and tibial conditions (such as slipped capital femoral epiphysis)
Septic arthritis
Limb- and life-threatening pathologies, including compartment syndrome
Dysvascular limb
Cervical spine trauma
Polytraumatized child

Patients ages 19 or more

Fractures
Open fractures (bone is exposed outside of a wound)
Open fractures or joints
Fractures with joint involvement
Isolated breaks
Stress fractures
Multiple fractures
Non-union fractures (fractures that do not heal)
Malunion fractures (fractures that heal incorrectly)
Acute compartment syndrome
Neurovascular injuries
Joint dislocations
Ligament sprains
Muscle strains
Tendon injuries
Septic joints
Cauda equina syndrome

10. Otolaryngological emergencies

What are examples of otolaryngological surgical emergencies?
Epistaxis
Peritonsillar abscess
Retropharyngeal abscess
Acute external otitis
Auricular hematoma
Mastoiditis
Facial nerve paralysis/Bell’s palsy
Ramsey-Hunt syndrome
Nasal fracture
Septal hematoma
Orbital blow-out fracture
Sudden sensorineural hearing loss (SSNHL)
The red herring tonsil
Dental abscess
Facial cellulitis
Ludwig’s angina
Deep neck space infections
Angioedema
Sinusitis: complications

11. Pediatric surgerical emergencies

What are examples of pediatric surgical emergencies?
Appendicitis
Bowel obstruction
Intussusception
Pyloric stenosis
Incarcerated inguinal hernia
Hirschsprung’s enterocolitis
Malrotation with volvulus
Necrotizing enterocolitis
The acute groin
Bleeding Meckel’s
Foreign bodies

12. Plastic and maxillofacial surgical emergencies

What are examples of plastic and maxillofacial surgical emergencies?
Trauma emergency
Facial trauma like an injury to the mouth, face, jaw, skull, scalp other structures that needs a surgical consultation
Corrective jaw surgery (misalignment of jaws and teeth that can improve chewing, speaking, and breathing)
Wisdom tooth is impacted
Temporomandibular joint surgery
Dental implants
Congenital cleft palate (plastic surgery at six months age)
Congenital cleft lip
Reconstruction of burned skin
Repair of complex wounds
Reconstructive procedures after congenital, acquired, and traumatic issues.

13. Urology emergencies

What are examples of urological surgical emergencies?
Acute urinary retention
Testicular torsion
Epididymo orchitis
Paraphimosis
Trauma to renal, ureteral, bladder, urethral, penile, testicular
Non-traumatic hematuria, renal colic, urinary retention, acute scrotum, paraphimosis.

14. Vascular Surgical Emergencies

What are examples of vascular surgical emergencies?
Arterial acute ischaemia
Arterial bleeding due to trauma
Venours, deep venous thrombosis
Venous pulmonary embolism
Lymphatic cellulitis
Compartment syndrome
Peripheral vascular disease
Occlusive blocked arteries

Alphabetical Listings
Surgical Emergencies
Surgical emergency is a medical emergency for which immediate surgical intervention is the only way to solve the problem successfully.

The following conditions are surgical emergencies:
  1. Abscesses

  2. Abscesses and fistulas (infections located around the anus and rectum)

  3. Acute abdomen that needs further diagnosis and treatment

  4. Acute airway obstruction

  5. Acute appendicitis

  6. Acute compartment syndrome

  7. Acute diverticulitis

  8. Acute external otitis

  9. Acute mesenteric ischemia

  10. Acute pancreatitis

  11. Acute subdural hematoma

  12. Acute trauma

  13. Acute urinary retention

  14. Airway obstruction

  15. Anal incontinence

  16. Anal sphincter repair

  17. Angioedema

  18. Aortic dissection

  19. Appendicitis

  20. Appendicitis

  21. Arterial acute ischaemia

  22. Arterial bleeding due to trauma

  23. Auricular hematoma

  24. Ballistic trauma or gunshot wound (GSW)

  25. Biliary colic and cholecystitis

  26. Bleeding ectopic pregnancy

  27. Bleeding Meckel’s

  28. Bowel obstruction

  29. Brain AVM (arteriovenous malformation)

  30. Cardiac tamponade

  31. Cataract surgery

  32. Cauda equina

  33. Cauda equina syndrome

  34. Cervical spine trauma

  35. Cholecystitis (gallbladder infection)

  36. Clinical signs of high ICP

  37. Compartment syndrome

  38. Congenital cleft lip

  39. Congenital cleft palate (plastic surgery at six months age)

  40. Cord compression

  41. Corneal and oculo-plastic surgeries

  42. Corrective jaw surgery (misalignment of jaws and teeth that can improve chewing, speaking, and breathing)

  43. Cosmetherapy, including botox, juvederm, and restylane

  44. Cushing response

  45. Deep neck space infections

  46. Dental abscess

  47. Dental extractions, including wisdom teeth

  48. Dental implants

  49. Dental implants and bone grafting

  50. Diverticulitis

  51. Dysvascular limb

  52. Epididymo orchitis

  53. Epidural hematomas

  54. Epidural hemorrhage

  55. Epistaxis

  56. Facial cellulitis

  57. Facial infection treatment

  58. Facial nerve paralysis/Bell’s palsy

  59. Facial trauma like an injury to the mouth, face, jaw, skull, scalp other structures that needs a surgical consultation

  60. Fissures (painful tears in the anal lining)

  61. Flail chest segment with pulmonary contusion

  62. Foreign bodies

  63. Fractures with joint involvement

  64. Fractures.

  65. Gastrointestinal perforation

  66. General oral surgery

  67. Glaucoma

  68. Head trauma

  69. Hemorrhage of rectum and anus

  70. Hemorrhoids with unstoppable bleeding or severe pain

  71. Hirschsprung’s enterocolitis

  72. Incarcerated hernia

  73. Incarcerated inguinal hernia

  74. Injury to the colon and rectum (stab wound)

  75. Internal bleeding

  76. Intestinal blockage/obstruction

  77. Intestinal volvulus

  78. Intracranial hemorrhage

  79. Intracranial lesions–focal

  80. Intussusception

  81. Isolated breaks

  82. Joint dislocations

  83. Jumped facets

  84. Ligament sprains

  85. Limb ischemia

  86. Limb- and life-threatening pathologies, including compartment syndrome

  87. Ludwig’s angina

  88. Lymphatic cellulitis

  89. Malrotation with volvulus

  90. Malunion fractures (fractures that heal incorrectly)

  91. Massive haemothorax

  92. Massive upper GI bleeding

  93. Mastoiditis

  94. Multiple fractures

  95. Muscle strains

  96. Nasal fracture

  97. Necrotizing enterocolitis

  98. Neurovascular injuries

  99. Non-traumatic hematuria, renal colic, urinary retention, acute scrotum, paraphimosis.

  100. Non-union fractures (fractures that do not heal)

  101. Occlusive blocked arteries

  102. Open fractures (bone is exposed outside of a wound)

  103. Open fractures or joints

  104. Open pneumothorax

  105. Open skull fracture

  106. Orbital blow-out fracture

  107. Paraphimosis

  108. Paraphimosis

  109. Penetrating injury

  110. Perforated abdominal viscus

  111. Peripheral vascular disease

  112. Peritonitis

  113. Peritonsillar abscess

  114. Pituitary adenoma

  115. Pituitary apoplexy

  116. Pneumothorax

  117. Polytraumatized child

  118. Pyloric stenosis

  119. Ramsey-Hunt syndrome

  120. Reconstruction of burned skin

  121. Reconstructive procedures after congenital, acquired, and traumatic issues.

  122. Rectal bleeding

  123. Rectal prolapse

  124. Repair of complex wounds

  125. Retained abortion

  126. Retinal detachment

  127. Retinal procedures

  128. Retropharyngeal abscess

  129. Ruptured aortic aneurysm

  130. Septal hematoma

  131. Septic arthritis

  132. Septic joints

  133. Shunt malfunction

  134. Sinusitis: complications

  135. Small bowel obstruction

  136. Spine fracture

  137. Stercoral perforation

  138. Strabismus

  139. Stress fractures

  140. Subarachnoid hemorrhage

  141. Sudden sensorineural hearing loss (SSNHL)

  142. Supracondylar humeral, femoral, and tibial conditions (such as slipped capital femoral epiphysis)

  143. T7-8 corpectomy and T6-T9 fusion

  144. Temporomandibular joint surgery

  145. Tendon injuries

  146. Tension pneumothorax

  147. Testicular torsion

  148. The acute groin

  149. The red herring tonsil

  150. Thrombosed hemorrhoids

  151. TMJ evaluations and management

  152. Trauma emergency

  153. Trauma to renal, ureteral, bladder, urethral, penile, testicular

  154. Traumatic compression fracture

  155. Treatment of facial trauma

  156. Uncal herniation

  157. Urinary retention

  158. Venous pulmonary embolism

  159. Venous, deep venous thrombosis

  160. Wisdom tooth is impacted

Obstetrical emergencies
  1. Abnormal vaginal bleeding

  2. Abortion with hemorrhagic shock

  3. Abruption of the placenta

  4. Acute abdominal pain during pregnancy

  5. Amniotic fluid embolism

  6. Antepartum hemorrhage

  7. Cardiopulmonary resuscitation during pregnancy

  8. Cesarean section under general anesthesia

  9. Cesarean section under local anesthesia

  10. Cesarean section without anesthesia

  11. Complete abortion

  12. Disseminated intravascular coagulation

  13. Eclampsia

  14. Ectopic pregnancy with shock

  15. Incomplete abortion

  16. Inevitable abortion

  17. Inversion of uterus

  18. Ovarian cyst, ruptured ovarian cyst

  19. Ovarian cyst, torsioned ovarian cyst

  20. Ovarian cyst, unruptured ovarian cyst

  21. Pelvic inflammatory disease mild

  22. Pelvic inflammatory disease moderate to severe

  23. Pelvic inflammatory disease tubo-ovarian abscess

  24. Placenta praevia

  25. Post-partum hysterectomy (see criminal matters with hysterectomy)

  26. Postmortem cesarean section

  27. Postpartum blues, puerpural depression, puerpural psychosis

  28. Postpartum hemorrhage

  29. Premature rupture of membranes

  30. Preterm labor and delivery

  31. Prolapsed umbilical cord

  32. Retained placenta

  33. Ruptured ectopic pregnancy

  34. Second trimester abortion

  35. Septic abortion

  36. Severe preeclampsia

  37. Shoulder dystocia

  38. Stillbirth and intrauterine death

  39. Third trimester delivery complication cesarean section

  40. Third trimester delivery complication immediate post-partum hemorrhage

  41. Third trimester delivery complication manual removal of the placenta

  42. Threatened abortion

  43. Trauma during pregnancy

  44. Unruptured ectopic pregnancy

Gynecologic surgical emergencies
  1. Adnexal torsion

  2. Ectopic pregnancies

  3. Gynecologic hemorrhage

  4. Hemorrhagic ovarian cysts

  5. Tubo-ovarian abscess

  6. Vulvovaginal trauma

What should you do before going ahead with any emergency surgery?
Verify diagnosis and alternative treatments with two other competent doctors. Document the findings of three separate doctors separately.

Experience has revealed that an individual who knows how to make an eight-inch incision and closing in three layers.
This individual is claiming to be surgeon specialist.
A surgical technician knows more than these skills.
Correct diagnosis of a human in various healthcare settings with various options of treatment is a prerequisite for all medical doctors.

Here are further guidelines.

http://www.qureshiuniversity.com/healthcareworld.htm

http://www.qureshiuniversity.com/surgerypatients.html

http://www.qureshiuniversity.com/surgeryworld.html

What should every type of physician know about a medical condition?
You should be able to elaborate on each medical condition mentioned in the questions.
Here are further guidelines:
What should you be able to elaborate about a medical condtion?

Listed in alphabetical order

Annotation or Definition
Causes
Complications
Diagnosis
Diagnostic tests
Disabilities associated with this medical condition
Emergencies associated with this medical condition
Epidemiology
History of this medical condition
Medical history relevant to this medical condition
Medical emergencies associated with this medical condition
Mechanism or pathogenesis
Normal values
Prevention
Relevant anatomy, physiology, or biochemistry
Risk factors
Research
Symptoms and signs
Types
Treatment or management

What should you be able to elaborate about a medical condtion?
    What is it?
    What causes it?
    What complications can occur?
    What are the risk factors?
    What's normal?
    How is it diagnosed?
    What are the symptoms?
    What are the signs?
    What are the clinical findings?
    What are the lab or investigation findings?
    What human anatomy should one know relevant to this medical condition?
    What human physiology should one know relevant to this medical condition?
    What human biochemistry should one know relevant to this medical condition?
    What human microbiology should one know relevant to this medical condition?
    How many such cases occur worldwide every year?
    How has diagnosis and treatment of this medical condition evolved?
    What medical history should you seek relevant to this issue?
    What happens in this medical condition?
    What research is being done on this issue?
    How can I help?
    How can you help?
    How is this medical condition reported?
    What should happen before reporting this medical condition?
    What are the types of this medical condition?
    What is the treatment?
    What are the workable treatment options?
    When is counseling required?
    When is medication required?
    How long should medication last?
    What type of medication is available?
    When is surgical intervention indicated?
    How could this be prevented?

What did you understand from these guidelines?

Regards and affection from Doctor Asif Qureshi, February 1, 2016, from Chicago, Illinois, North America to Zakia in Medina. What did you understand?

If you have any questions or issues, email Doctor Asif Qureshi at admin@qureshiuniversity.com, call 7735616102 Chicago, Illinois, North America.

Critical care unit
ICU Medical Conditions

What medical conditions are treated within a critical care unit?
  1. Acute Respiratory Failure.

  2. Acute renal failure.

  3. Cardiac dysrhythmia.

  4. CO2 retention

  5. Diabetic Coma in Type 2 Diabetes

  6. Diabetic Ketoacidosis (DKA)

  7. Heart Failure

  8. Medical conditions that need further evaluation and treatment in a critical care unit.

  9. Multiple organ failure.

  10. Polytrauma

  11. Poisoning & Drug Overdose

  12. Post-operative Intensive Care

  13. Respiratory (Lung) Failure

  14. Renal conditions that need critical care services or dialysis

  15. Septicemia.

  16. Shock

  17. Stroke

  18. Trauma

  19. Traumatic Brain Injury.

  20. Unconsciousness or Coma

  21. Others.


What are various types of care units within a critical care unit?
Neonatal intensive care unit (NICU)
Pediatric intensive care unit (PICU)
Psychiatric intensive care unit (PICU)
Coronary care unit (CCU): Also known as cardiac intensive care unit (CICU)
Post-anesthesia care unit (PACU)
High dependency unit (HDU)

Monitoring the critically ill patient
What should you monitor in a critically ill patient relevant to age?
1. Level of consciousness
2. Pulse
3. Blood pressure
4. Respiratory rate (ventilated and/or non-ventilated)
5. Oxygenation SpO2
6. Temperature (core)
7. Urine output in 1 hour and in 24 hours
8. Pain
9. Complaint/complaints if any:

Do you have any complaints or problems now?
What complaints or problems do you have now?
How should this complaint be resolved?

Nine vital signs must be monitored in a critically ill patient.
If normal, do not proceed with any invasive or complicated analysis.
If all nine vital signs are normal, it means the individual is normal now.
He/She may have been critically ill previously.

What should be monitored if any of the eight vital signs are low or high relevant to age and medical condition?
Arterial pH
Serum sodium
Serum potassium
Serum Urea
Serum creatinine
Glucose
Hematocrit
White blood cell count
Glasgow coma score

What standard of human blood serum chemistry normal values do you follow?
What standard of human blood serum chemistry normal values do I follow?
http://www.qureshiuniversity.com/BloodSerumChemistryNormalValues.pdf

What resources are essential for a critical care unit (CCU)?
Internet with www.qureshiuniversity.com.
Critical care unit staff.
Critical care unit beds in a room.
Critical care unit equipment.

Is an intensive care unit included in emergency medical services inside and outside the state?
Yes.

Why is an intensive care unit included in emergency medical services inside and outside the state?
There are 21 medical emergency diagnoses that have to be admitted to an intensive care unit.
Here are further facts.
http://www.qureshiuniversity.org/intensivecareunit.html

Physician intensive care unit
http://www.qureshiuniversity.com/criticalcareworld.html

What should you keep in mind during the diagnosis and treatment of human being in various healthcare settings?
Diagnoses and treatments of human beings should proceed relevant to age, gender, and type of human healthcare complaint.

How many human healthcare settings are there?
There are 10 human healthcare settings. If some settings are considered differently, then there are 21 human healthcare settings.

What are the various human healthcare settings?
Internet human healthcare is one of the human healthcare settings.
http://www.qureshiuniversity.com/humanhealthcaresettings.html

Is there a difference between on-the-spot diagnosis and treatment and spot diagnosis?
Yes.

What will happen if diagnosis and treatment are delayed in these situations?
A person can die, a disability can occur, and irreparable harms can occur.

Spot diagnosis by specific physicians.
An ECG is given to you for spot diagnosis.
An altered gait (walking) child is spotted for diagnosis (August 3, 2015, Chicago, Illinois).

What are the 10 human healthcare settings?
What is on-the-spot diagnosis and treatment?
Who can offer on-the-spot diagnosis and treatment?
What problems, complaints, incidents, and issues need on-the-spot diagnosis and treatment?

http://www.qureshiuniversity.org/onthespotemergency.html

Is there a difference between an ambulance (road) and non-emergency medical transport?
Yes.

What is the difference between an ambulance (road) and non-emergency medical transport?
An ambulance (road) is meant for medical emergencies.
A non-emergency medical transport service is provided to individuals who are not in an emergency situation but need more assistance than a taxi service is able to provide.

What is non-emergency medical transport and how can it benefit you?
A non-emergency medical transport service is provided to individuals who are not in an emergency situation but need more assistance than a taxi service is able to provide.

Emergency medical record printing.
What is an emergency medical record?
A physician, medical emergency responder, or the equivalent evaluates a patient on the spot. This is written on a paper document called an emergency medical record.

What should be printed on an emergency medical record?
http://www.qureshiuniversity.com/emergencymedicalrecord.html

Listing of emergency medical rooms in the state and intensive care units in the state.
What states must make these facts available?
http://www.qureshiuniversity.org/states.html

How many total medical emergency rooms are in the state?
What is the location or mailing address of the medical emergency rooms in the state?
How many intensive care units are in the state?
What is the location or mailing address of the intensive care units in the state?

Duties of the director of emergency medical services in the state.
What are the duties of the director of emergency medical services in the state?
Supervise, verify the availability of relevant emergency medical services with proper staff, and elaborate on facts at www.qureshiuniversity.com/medicalemergency.html.

Emergency Diagnosis and Treatment
What are the types of patient assessment?
Patient 60-second assessment by call center/Internet/telemedicine.
Patient 60-second on-the-spot diagnosis and treatment.
Patient 60-second assessment in trauma.
Patient 10-minutes assessment in a medical emergency room.
Patient-focused history and physical exam.
Comprehensive patient assessment.

What are Emergency Medical Services in the state or outside the state?

Why was there a need to explain definition of Emergency Medical Services in the state or outside the state?

Some consider emergency medical services as providing out-of-hospital acute medical care.
Emergency medical services are out-of-hospital on the spot, on the spot to medical emergency room, in medical emergency room, in an operating room or in an intensive care unit.


On-the-spot emergency medical diagnosis and treatment
Human healthcare issues requiring on-the-spot diagnosis and treatment.
Where do we start in human healthcare?
Evaluation of a patient on the spot by an emergency medical responder, a physician.

How many human healthcare issues need on-the-spot diagnosis and treatment?
8

What human healthcare issues need on-the-spot diagnosis and treatment?
USTBDSSM(8) is the abbreviation.
1. Unconsciousness at a public place
2. Sudden unconsciousness at home
3. Trauma of various types
4. Burns
5. Drowning
6. Seizures
7. Survival needs issues of a person
8. Medico-legal cases with criminal activities, including women’s pregnancy issues

Glasgow Coma scale analysis.

Glasgow Coma scale analysis.

First, analyze Glasgow Coma scale, then analyze vital signs including consciousness.

When was the patient normal?
Can the patient open both eyes spontaneously?
Can the patient talk or make noise relevant to age?
Can the patient walk or move extremities relevant to age?

If yes, Glasgow Coma scale is 15.
Glasgow Coma scale of 15 means the patient is not in a coma.
The patient can have less serious medical issues.
Go ahead with vital signs, including consciousness.

When should you do on-the-spot endotracheal intubation?
If Glasgow coma scale is 9 or less with airway obstruction, even with gag reflex, you should intubate the patient. Do you know how to calculate Glasgow coma scale?
How do you intubate a patient in coma with Glasgow coma scale less than 9 with gag reflex in respiratory distress?

When should you start an on-the-spot intravenous line?
If there is blood loss with hypotension.
In case of cardiopulmonary arrest.

Cardiopulmonary resuscitation if required.

The nearest hospital with critical care is 20 minutes by vehicle.
In case of head injury with coma, prolonging diagnosis and treatment for 20 minutes may cause patient to die.

That is what happened in this case.
Patient died even though seen by a neurosurgeon and an anesthetist.

Medical emergency diagnosis and treatment of trauma with coma with respiratory distress, or imbalance in circulation, should happen within 4-6 minutes of occurrence or report of a medical emergency.

Is that clear?
Do you have any questions for me?

Ability to perform calculations: Can the patient perform simple addition, multiplication, subtraction, and division? Are the responses appropriate for the patient’s level of education?
Are there any problems in calculations?

Consciousness

Level of alertness: Is the patient conscious?
If not, can the patient be awakened?
Can the patient remain focused on your questions and conversation?
What is attention span of the patient?

In case of altered sensorium, get answers to these questions.

How would you rate Glasgow Coma Scale of this patient in the range of 3—15, with a score of 3 indicating brain death (the lowest defined level of consciousness), and 15 indicating full consciousness?

Language

How are English language understanding, reading, writing, and speaking abilities of the individual?
The individual can understand, read, write, and speak the English language.
The individual is unable to understand, read, write, and speak the English language.

Assessment by medical emergency specialist in emergency medical situation.

What should be your focus of assessment in an emergency medical situation?
Vital signs, including consciousness.
No pain, wounds, or abnormal findings that needs emergency treatment.
Glasgow coma scale.
Mobility assessment (Is individual able to walk or make limb movements relevant to age?)
Survival needs assessment.
Emotion: Anger, sadness, fear or emotions not relevant to situation need further evaluation

Criteria for discharge from medical emergency room

1. Vital signs including consciousness: Normal
2. Glasgow coma scale: 15.
3. Mobility assessment: Normal.
4. Survival needs assessment: Yes.
5. Emotions: Normal relevant to situation.
6. Psychiatric evaluation if required: Normal

Emergency diagnosis and treatment and disability assessment are two different assessments.
For example, a person can be 100% mentally fit and 95% physically fit.

This is relevant to the individual’s age.
1. Vital signs including consciousness: Normal

Are vital signs including consciousness normal?
Yes.

No pain, wounds, or abnormal findings that needs emergency treatment.

2. Glasgow coma scale: 15.

Is Glasgow coma scale 15?
Yes.

3. Mobility assessment

Is individual able to walk or make limb movements relevant to age?
Normal

4. Survival needs assessment.

Does the individual have survival needs form the state?
Yes.

Is it safe for the individual at the residence?

5. Emotions: Anger, sadness, fear, or emotions not relevant to situation needs further evaluation. Normal.

Are emotions expression normal relevant to situation?

6. Psychiatric evaluation if required.

Is this individual mentally fit relevant to age?

Advice on discharge from medical emergency room.
This depends on original complaint and diagnosis with relevant treatment.
Treatment depends on the underlying cause.

What best describes the individual’s emotions at this point?

Basic life support

What should you know about basic life support?
Basic life support is meant for an unconscious patient.
All unconscious patients need basic life support.
Not all unconscious patients need cardiopulmonary resuscitation (breathing support, chest compressions). Only unconscious patients with cardiac arrest or respiratory arrest need cardiopulmonary resuscitation including breathing support and chest compressions).

Does the unconscious patient need basic life support with CPR or without CPR?

If the unconscious patient needs basic life support with cardiopulmonary resuscitation with chest compressions here are further guidelines.
Cardiopulmonary resuscitation guidelines.

Unconscious patient.

What type of patient needs basic life support?
An unconscious patient.

Do all unconscious patients need cardiopulmonary resuscitation?
No.

How should you evaluate and treat an unconscious patient?
Assessment is very important.
Not all unconscious patients need cardiopulmonary resuscitation.
For adults, assess the victim, activate EMS and get AED, check pulse, start CPR.

When do you start cardiopulmonary resuscitation in adults?
CPR is required someone's breathing or heartbeat has stopped, as in cases of electric shock, drowning, or heart attack. CPR is a lifesaving procedure in this situation.

What is cardiopulmonary resuscitation?
Cardiopulmonary resuscitation is a combination of rescue breathing and chest compressions.
Rescue breathing provides oxygen to a person's lungs.
Chest compressions keep the person's blood circulating.
Permanent brain damage or death can occur within minutes if a person's blood flow stops. Therefore, you must continue these procedures until the person's heartbeat and breathing return, or trained medical help arrives.

In what situations is a directive like "Do not Resuscitate" justified?
Old age more than 95 years with known complications.

What is unconsciousness?
Unconsciousness means being unable to see, hear, and talk.
Often, this is called a coma or being in a comatose condition.
An unconsciousness person will be unresponsive to activity, touch, sound, or other stimulation.
He or she will not be able to communicate and won’t respond to stimulation.

Conscious means able to see, hear, and talk.
In pediatric patients younger than six months of age, the ability to make any verbal noise or cry is equivalent to talking.

A person may be unconscious for a few seconds (as is the case with fainting) or for longer periods of time.

What are the causes of unconsciousness?
Alcohol use.
Drowning.
Electric shock
Substance abuse
Severe blood loss
8 H's and 6 T's: mnemonic for mechanisms
Hypoxia
Hypovolemia
Hyperkalemia
Hypokalemia
Hypoglycemia
Hypothermia
Hyperthermia (heat stroke)
Hydrogen ions (acidosis)
Thrombosis (MI/heart attack)
Tension pneumothorax
Tamponade
Toxins/therapeutics
Thromboembolism
Trauma

What is the difference between being asleep and being unconscious?
Being asleep is not the same thing as being unconscious.
A sleeping person will respond to loud noises or gentle shaking; an unconscious person will not.

An unconscious person cannot cough or clear his or her throat. This can lead to death if the airway becomes blocked.

Is there a difference between unconsciousness and cardiopulmonary arrest?
Yes.

What is the difference between unconsciousness and cardio pulmonary arrest?
Unconsciousness is usually without cardiac arrest.
If unconsciousness is associated with cardiac arrest or respiratory arrest, cardiopulmonary resuscitation is required.

http://www.qureshiuniversity.com/comadiagnosis.html

How does one diagnose and treat an unconscious patient?

Eye Opening

Can the patient do spontaneous eye opening?
Is the patient capable of opening eyes to speech, to stimulus, to pain not applied to face, breast, genitals or not opening his/her eyes?

Spontaneous eye opening ? 4 points
Opens to verbal command, speech, or shout ? 3 points
Opens to pain, not applied to face ? 2 points
None ? 1 point

Verbal Response

Oriented ? 5 points

Is patient confused?
Confused conversation, but able to answer questions ? 4 points

Is patient making inappropriate responses?
Inappropriate responses, words discernible ? 3 points

Can patient make any incomprehensible spoken sounds or no spoken sounds?
Incomprehensible speech ? 2 points
None ? 1 point

Motor Response

Can patient move all extremities when instructed?
Obeys commands for movement ? 6 points

Can patient do purposeful movement to painful stimulus?
Purposeful movement to painful stimulus ? 5 points

Can patient withdraw from painful stimulus?
Withdraws from pain ? 4 points

Is there any spasticity or rigidity?
Abnormal (spastic) flexion, decorticate posture ? 3 points
Extensor (rigid) response, decerebrate posture ? 2 points
Is there any movement of extremities?
None ? 1 point

Did the coma start abruptly or gradually?
Were there problems with vision, dizziness, or numbness beforehand?
What is the Glasgow Coma Scale?
How is the Glasgow Coma Scale helpful?
Can a patient's diagnosis and treatment be done without the Glasgow Coma Scale?
How do you define coma?
What is the mathematical value of coma?
Is evaluation of coma in adults different than in children?
Here are further guidelines.
Critical Care
Medical emergencies.

What is on-the-spot diagnosis and treatment?

This example will make you understand.
On November 30, 2012, Aswell Salmon, 46 years old, was shot at 9:27 p.m. near the 5000 block of North Winthrop Avenue, Chicago, Illinois.
He died more than 30 minutes later.
This needed on-the-spot diagnosis and treatment within five minutes of the incident.
Transfer to a hospital was required after on-the-spot diagnosis and treatment.

Was this death preventable?
Yes.

What is the cause of death in this scenario?
Criminal conspiracy.
Criminal Violence.
Delayed Diagnosis.
Wrong Diagnosis.
Wrong Treatment.
Trauma due to shooting.
Gunshot wounds at three sites of the body (leg, buttocks, and chest).
Witnesses report that patient was alive 30 minutes after the shooting.

What is the original spot of the medical emergency?

The location where the incident occurs is the original spot of the medical emergency. Certain problems, complaints, incidents, and issues need on-the-spot diagnosis and treatment.

All medical emergencies on the spot, including trauma, must be attended by a medical doctor.

Experience has shown that police and military officers are the first to get updates about trauma, and then health care professionals, including medical doctors, are updated.

Because police or military officers are the first to be updated about trauma, if they have medical doctors’ skills and knowledge of on-the-spot diagnosis and treatment, this is going to prevent various premature or unexpected deaths.

Recovery from a medical condition
What is recovery from a medical condition?

The process of returning to normal activity after an illness or injury.

What can be the location of recovery from a medical condition?

ER, ICU, ward, rehabilitation facility, or at home, depending on the severity of the medical condition.

When can a patient recover from medical condition at home?

If consciousness, pulse, blood pressure, temperature, respiratory rate, behavior, and mobility relevant to age are normal without any acute external or internal injury, and proper survival and civilized conditions exist at home, the patient can recover from the medical condition at home.

Internet health care/home/home office or OPD

How many medical conditions can get health care via Internet health care/home/home office or OPD?

More than 6,000 medical conditions.

Here are further guidelines.
Here are further guidelines.

Occupations relevant to this department in the state.
What are the types of emergency medicine specialist?
  1. Emergency medicine specialist (first responder)/Physician medical emergency responder

  2. Emergency medicine specialist (medical emergency room)/Physician medical emergency room

  3. Emergency medicine specialist (dispatcher)

  4. Guide for emergency medicine specialist

  5. Physician intensive care unit

  6. Physician surgeon medical emergency

  7. Physician anesthetist medical emergency

  8. Emergency Management Director

  9. Director, Office of Emergency Medical Services

    Subordinates

    What is subordinate?
    An employee ranked below another employee in terms of seniority or office hierarchy.


  10. EMR (Emergency Medical Responder)

  11. EMT (Emergency Medical Technician)

  12. AEMT (Advanced Emergency Medical Technician)

  13. Emergency Medical Services (EMS) Instructor

  14. Emergency Medical Services Lab Assistant

  15. Paramedic

  16. Ambulance Drivers and Attendants, Except Emergency Medical Technicians

What should an emergency medicine specialist (first responder, medical emergency room, dispatcher), Guide know about emergency medical services?
  1. Annotation or definition of Emergency Medical Services.

  2. Analysis of complaints, incidents, issues, and problems

  3. Assessment of a patient in medical emergency by an emergency medicine specialist

  4. Blood Alcohol Concentration (BAC)

  5. Cardiopulmonary Resuscitation (CPR)

  6. Criteria for emergency medical services

  7. Critical and noncritical medical emergency

  8. Criteria for discharge from medical emergency room

  9. Difference between an emergency room physician and physician at other locations.

  10. Emergency Medicine Specialist Training Programs

  11. Examples of emergency medical diagnosis and treatment

  12. Examples of emergency symptoms, signs, and complaints

  13. Equipment relevant to medical emergency

  14. Emergency medical record

  15. Emergency medications

  16. EMS education coordinator program

  17. Emergency Medicine Procedures

  18. Emergency medical services (EMS) systems act.

  19. Essential services maintenance act.

  20. Emergency diagnosis and treatment.

  21. Evaluation of a patient in an emergency room by emergency room physician.

  22. Emergency Patient Assessment

  23. Evaluation of a patient on the spot by an emergency medical responder, a physician.

  24. Emergency room physician telephone conversation.

  25. Eye Conditions

  26. Glasgow Coma Scale

  27. Human Vital Signs

  28. Intravenous fluids

  29. Inspections of all emergency medical equipment and supplies

  30. License status

  31. Life support

  32. Medically related educational programs

  33. Medical accountability of the EMS

  34. Mass casualty units

  35. On-the-spot emergency medical diagnosis and treatment

  36. Pediatric Basic and Advanced Life Support

  37. Portable electro-cardiac monitor and defibrillators

  38. Preventve maintenance on all vital medical equipment

  39. Survival needs monitoring

  40. Symptoms, signs of medical emergencies.

  41. Surgical Skills

  42. Telephone assessment by emergency medicine specialist (dispatcher)

  43. Types of ambulances (Road)

  44. Urine Drug Test

Assessment of a patient in medical emergency by an emergency medicine specialist
Assessment in medical emergency situation.
Assessment by medical emergency specialist in emergency medical situation.

What should be your focus of assessment in an emergency medical situation?
1. Glasgow coma scale.
2. Vital signs, including consciousness.
3. No pain, wounds, or abnormal findings that needs emergency treatment.
4. Mobility assessment (Is individual able to walk or make limb movements relevant to age?)
5. Survival needs assessment.
6. Emotion: Anger, sadness, fear or emotions not relevant to situation need further evaluation
7. Psychiatric evaluation if required: Normal

What are other names for emergency medical specialist?
Emergency physician

How are emergency medical Services abbreviated in various states?
EMS (emergency medical services). EMS also is elaborated as Express Mail Service.
To avoid confusion, elaborate emergency medical services fully.

Who should do evaluation or treatment of patient on the spot, on the way to the hospital, and in the emergency room?
A physician should do this job.
On the spot and on the way to the hospital, one physician should attend.
If the patient needs emergency room treatment, the case should be handed over to another physician in the medical emergency room.

What are other names for emergency medical services in various states?
Emergency squad
Rescue squad
Ambulance squad
Ambulance service
Ambulance corps
Life squad

Paramedic service, a first aid squad, is not an appropriate term for emergency medical service. Emergency medical services have to be provided by a physician on the spot, on the way to the hospital, and in the hospital.

How do you contact an emergency medical service in the state?
Every state has an emergency telephone number.
An emergency telephone number operator, who should also ideally be a physician, puts them in contact with a control facility, which will then dispatch a suitable resource to deal with the situation.

In some parts of the world, emergency medical service also encompasses the role of moving patients from one medical facility to an alternative one.

What have been findings of emergency medical services in various states in North America?
A physician should take care of patient on the spot and on the way to hospital.
Paramedics who are not able to reach to correct diagnosis and treatment and education of only basic life support (BLS) or advanced life support (ALS) personnel, including paramedics and nurses, were only available up to March 1, 2015.

What is the job title of a physician who has the duty to evaluate and treat various emergency medical complaints?
Emergency medicine specialist.
A junior emergency medicine specialist attends on the spot.
A senior emergency medical specialist provides guidance through the Internet from a distance, for example the guidelines displayed here.

How many emergency medical specialists (first responder) are required in every state?
We will take example of Chicago, Illinois.
On March 8, 2015, there were 60 ALS ambulances and 15 BLS ambulances in Chicago, Illinois. 300 emergency medical specialists (first responder) were required in Chicago, Illinois on March 8, 2015.

How many emergency medical specialists (first responder) were there in Chicago, Illinois on March 8, 2015?
Almost negligible.

Is there a difference between an emergency medical specialist (first responder) and an emergency medicine specialist (medical emergency room)?
Yes.

What is the difference between an emergency medical specialist (first responder) and emergency medicine specialist (medical emergency room)?
Emergency medical complaint evaluation, diagnosis and treatment of out-of-hospital acute medical situation is the job of an emergency medical specialist (first responder) up to the medical emergency room.

The job location of an emergency medicine specialist (medical emergency room) is in a medical emergency room. An emergency medicine specialist (medical emergency room) can receive walk-in patients; others can bring the patient, referrals, or via ambulance.

Emergency medicine specialist or senior emergency medical specialist guide communicates through Internet from a distance, for example the guidelines displayed here.

Why is there a need for an emergency medical specialist (first responder)?

Is this medical situation undetermined, good, fair, serious, or critical?
What is the diagnosis?
What is the treatment?

An emergency medicine specialist has to answer these questions.

What staff is associated with emergency medical services in the state or outside the state?
First responder (ideally should be emergency medicine specialist)
Emergency medicine specialist (medical emergency room)
Guide for emergency medicine specialist
Ambulance driver
Ambulance care assistant
Emergency medical technician
Emergency medical dispatcher
Paramedic

What should an emergency medicine specialist know?
Here are further guidelines
http://www.qureshiuniversity.com/medicalemergencyworld.html
Is there a difference between analysis of complaints, incidents, issues, problems, and assessment of a patient?
Yes.

What is the difference between analysis of complaints, incidents, issues, problems, and assessment of a patient?
Assessment of patient includes:
Analysis of complaints, incidents, issues, and problems.
Physical examinations if required.
Lab investigations if required.
Diagnosis.
Treatment.


Analysis of complaints, incidents, issues, and problems.

What should be your first question in case a patient is referred to you?

Assessment in medical emergency situation.

Questions that must be answered.

Where is the patient now?
How old is the patient?
What is the gender of the patient?
Who is reporting this emergency?
What seems to be the complaint?
What seems to be the problem?


Glasgow Coma scale analysis.

First, analyze Glasgow Coma scale, then analyze vital signs including consciousness.

When was the patient normal?
Can the patient open both eyes spontaneously?
Can the patient talk or make noise relevant to age?
Can the patient walk or move extremities relevant to age?


If yes, Glasgow Coma scale is 15.
Glasgow Coma scale of 15 means the patient is not in a coma.
The patient can have less serious medical issues.
Go ahead with vital signs, including consciousness.

When did it start?
How did it start?
Where did it start?
How much time has elapsed from the start of the emergency until now?
What do you think causes it?
What do I think caused it?
What needs to be done to verify what caused it?
Has patient taken any medication or substance before this issue?
Has any specific thing happened that led to this issue?
Is this troubling your everyday activity?
How is this troubling your everyday activity?
Does one individual or many individuals have medical emergencies at this location?
How many individuals have medical emergencies at this location?
Is it a medical emergency?

___________________________

In what type of setting does this patient need treatment?

___________________________

Do any recent causes lead to this problem; for example, trauma, missed medication, inadequate survival needs, stress, or other issue?

___________________________

What are further details?

___________________________

Does any past medical history lead to this problem?

___________________________

Is there any recent history within past few minutes or hours of any of the following:
1.Unconsciousness at a public location.
2.Sudden unconsciousness at home.
3.Trauma.
4.Survival needs issues.
5.Seizures.
6.Burns.
7.Drowning.

___________________________

If there is even one recent history of the above, on the spot diagnosis and treatment is required.

Is the victim's condition life or limb threatening?

___________________________

Could the victim's condition worsen and become life or limb-threatening on the way to the hospital?

___________________________

Could moving the victim cause further injury?

___________________________

Would distance or traffic conditions cause a delay in getting the victim to the hospital?

___________________________

What have been his activities for the last 10 years?

___________________________

Does the individual use or abuse any of these substances?
Alcohol.
Drugs.
Tobacco.

___________________________

Is the individual on any medication?

___________________________

Questions doctor on duty needs to answer.

Is it a medical emergency?

___________________________

Does this need on-the-spot diagnosis and treatment?

___________________________

What is the most likely diagnosis?

___________________________

What do you think causes it?

___________________________

Why do you think this happened?

___________________________

What is the diagnosis?

___________________________

In what setting/location does this medical condition need treatment?
Treatment required on the spot.
Treatment required in the medical emergency room.
Treatment required in the intensive care unit.
Treatment required in the ward.
Treatment required in the operating room.
Treatment required at home.
Treatment required Internet health care.
Treatment required in OPD consultation.
___________________________

What treatment do you recommend for this patient?

___________________________

What are other treatment options for this patient?
No other treatment option.
Other treatment options are enumerated.

___________________________

Here are further guidelines.
A medical emergency with an individual victim.
A multiple casualty incident.
Harms Evaluation/Medico-legal
Here are further guidelines.
Here are further guidelines.
Do you think this is a multiple causality incident?

If it is a multiple causality incident, the guidelines are different.

What problems, complaints, incidents, and issues need on-the-spot diagnosis and treatment?
  1. Unconsciousness at a public location.

  2. Sudden unconsciousness at home.

  3. Trauma

  4. Survival Needs

  5. Seizures

  6. Burns

  7. Drowning

  8. Human Pregnancy Emergencies

  9. Here are further guidelines.
Conscious
Can the patient talk?
Can the patient respond to verbal questions accurately?
Can the patient do spontaneous eye opening?
Does the patient respond to painful stimulus?
Is the patient conscious, oriented in time, space, and person?


Conscious means able to see, hear, and talk.
In pediatric patients younger than six months of age, the ability to make any verbal noise or cry is equivalent to talking.

What best describes you in a medical emergency?
  1. Doctor in a medical emergency.

  2. Emergency responder in a medical emergency.

  3. Emergency Call Center in a medical emergency.

  4. Watcher, relative, or acquaintance of the victim in a medical emergency.

  5. Victim himself or herself in a medical emergency.

  6. The role of www.qureshiuniversity.com/medicalemergencyworld.html in a medical emergency.


What is wrong with existing physicians around the world?
Existing physicians around the world are not able to do proper health care assessment in various human healthcare settings.

Existing physicians are not able to reach correct diagnoses and treatment in various human healthcare settings.

How many types of human health care assessment are there?
There are 18 types of human health care nonemergency assessment and 15 types of human health care, emergency assessment in various human healthcare settings.

What is an assessment of a patient?
Patient assessment is the term used to describe the process of identification of the condition, needs, abilities, and genuine preferences of a patient. Identify possible solutions and/or remedies.
Prepare a plan.

Who should ideally do an assessment of a patient?
The physician should ideally do an assessment of the patient.

There is only one best doctor on this planet.

His name: Dr. Asif Qureshi.
His focus: The planet.

Questions relevant to the patient.

Here are further guidelines.

PATIENT ASSESSMENT DEFINITIONS
Emergency Medical Services.
Here are further guidelines.

Emergency medical room in a hospital
Here are further guidelines.

Primary care physician consultation
New patient relevant to primary health care (nonemergency).
Here are further guidelines.

What is a Medical Emergency?
Who are the people behind 911 or emergency call responders?

Ideally, an experienced competent medical doctor should be behind 911 or emergency call responders.

What is the role of www.qureshiuniversity.com/medicalemergencyworld.html in a medical emergency?
Guide the following:
Doctor in a medical emergency.
Emergency responder in a medical emergency.
Emergency call center in a medical emergency.
Watcher, relative, or acquaintance of the victim in a medical emergency.
Victim himself or herself in a medical emergency.
Guide the state department of health worldwide.
Administrative Issues
Emergency Diagnosis Code
Assessment of the newborn infant
Annual Physical Examinations
OUTLINE FOR PEDIATRIC HISTORY & PHYSICAL EXAM

Ambulance
Types of ambulances (Road)
Why do you need to mention road ambulance?
Nowadays there are air ambulances as well.

What are the types of road ambulance?
ALS ambulances
BLS ambulances

How many total road ambulances are there in the state?
What are the types of ambulances in the state?
What is the area-wide number of ambulances in the state?
For example Chicago, Illinois, on March 8, 2015, had 60 ALS ambulances and 15 BLS ambulances.
What type of ambulance will be associated with you?

What are salient features of emergency medical ambulances?
All ALS and BLS ambulances, and ALS engines, are equipped with state-of-the-art telemetry radio equipment, which allows emergency medical responders to radio important information from the scene of the incident directly to a nearby hospital, where physicians can review the patient’s condition and provide further medical instructions and transport information.

What is Non-Emergency Medical Transport and How Can it Benefit You?
Generally, NEMT is defined as a transportation service provided to individuals who are not in an emergency situation but need more assistance than a taxi service is able to provide. Often times, these services are specially equipped to transport riders in wheelchairs, stretchers or with other special needs.

Non-Emergency Transportation (Certificate of Public Convenience and Necessity)

Providers of non-emergency transportation require a Certificate of Public Convenience and Necessity. This service includes the transportation of persons on stretchers, using wheelchairs, or whose incapacitation makes it impractical for them to be transported by a regular carrier, and who neither need, nor expect to need medical attention en route.

Non-Emergency Medical Transportation

Wheelchair transportation
Ambulatory services
One-way & round-trip medical transport
Flat rate private pay non-emergency medical transport
Rides to doctor offices, nursing homes, physical therapy

Ambulance

What is an Ambulance?
An ambulance is a vehicle for transportation of sick or injured people to, from or between places of treatment for an illness or injury, and in some instances will also provide out of hospital medical care to the patient.

Equipment for Ambulances

REQUIRED EQUIPMENT: BLS AMBULANCES
REQUIRED EQUIPMENT: ALS AMBULANCES
OPTIONAL BASIC EQUIPMENT
OPTIONAL MEDICATIONS

What types of physicians must be on an ambulance?
This ambulance must have a physician medical emergency responder (first responder).
The physician medical emergency responder (first responder) is also known as emergency medicine specialist (first responder).

If a physician medical emergency responder must respond to on spot medical emergency through emergency medical services with an ambulance, why do we need EMR (Emergency Medical Responder), EMT (Emergency Medical Technician), AEMT (Advanced Emergency Medical Technician), Emergency Medical Services (EMS) Instructor, Paramedic as medical emergency responders? There are few physician medical emergency responders, physician medical emergency rooms and physician intensive care units available.

Because of the lack of physician medical emergency responders, EMRs (Emergency Medical Responder), EMTs (Emergency Medical Technician), AEMTs (Advanced Emergency Medical Technician), and Emergency Medical Services (EMS) Instructors, paramedics are required in certain situations.

What do states have to do about emergency medical responders?
Standardize emergency medical responder levels.
Emergency medical specialists (first responders) also known physician medical emergency responders or the equivalent must be first responders among emergency medical responders.
Here are further guidelines.
http://www.qureshiuniversity.org/medicalemergency.html

Is there any recent history within past few minutes or hours of any of the following:
1.Unconsciousness at a public location.
2.Sudden unconsciousness at home.
3.Trauma.
4.Survival needs issues.
5.Seizures.
6.Burns.
7.Drowning.
8.Medicolegal case

___________________________

If there is even one recent history of the above, on the spot diagnosis and treatment is required.
Here are further guidelines.
http://www.qureshiuniversity.com/health.html

What are various symptoms, signs, statements, questions, issues, and histories that should raise suspicion of a medical emergency?
There are at least 161 such symptoms, signs, statements, questions, issues, histories, and scenarios.
http://www.qureshiuniversity.org/medicalemergency.html#Symptoms, signs of medical emergencies.

How many human medical emergencies are there?
There are fewer than 1,150 human medical emergencies.
If you know the human medical conditions, then you will be able to diagnose and treat them.
Here are further guidelines.
http://www.qureshiuniversity.com/emergencymedicine.html


How many human medical conditions are there?
There are more than 7,000 human medical conditions.

What patients need intensive care?
Here are further guidelines.

Assessment in medical nonemergency situation.
How should you do assessment in a medical nonemergency situation?
Is it a human healthcare complaint or a nonhuman healthcare complaint?

Why is the answer to this question essential?

A complaint can be relevant to more than 40 departments in the state or outside the state.
A human healthcare complaint is one of them.

What should an emergency medical specialist verify in the community?

Are there competent primary care physicians in the community?
Is it safe to live in the community?


Assessment in a medical nonemergency situation

Consultation through Internet.

Doctor Consultation
Patient Profile
Individualized consultation nonemergency patient
Comprehensive patient assessment
How is a comprehensive patient assessment done?
Take a look at this.
Questions you need to answer.

How should you answer these questions?
Answer to the best of your ability and knowledge.

What should you write if a question is not applicable to you?
This is not applicable to me at this point.

What seems to be the issue?

What is the name and date of birth of the patient?

What is your Email address?

What is the name of the individual who needs doctor consultation?

What is the date of birth of the individual who needs doctor consultation?

Address

What is your mailing address?

What was your mailing address from birth until now?

Where is the patient now?

Where do you live now?
How long have you lived at this address?

How long do you plan to live at this address?

What is your contact information including current mailing address, telephone, e-mail, and any other details, and person to contact in case of emergency?

What is the gender of the patient?

What best describes the patient?
Child Adolescent girl Adolescent boy Woman Man

In general, how is your physical and mental health? Excellent Good Fair Poor

What is your telephone number?

Have you been in the hospital in the last month?
Yes
No

Do you have health problems that you need help with right away?
Yes
No

Do you have any appointments scheduled with doctors or other specialists?
Yes
No

Screening for survival needs

Do you have enough of these resources from the state?
Food
Clothing
Housing
Health care
Transportation
Security
Education
Consumer goods
Communication

Do you need any of these resources to be enhanced?

What are the issues?

Do you need extra help to access services, such as a wheelchair ramp, a computer screen reader or large print materials?
Yes
No

What is the number on your medical card?
A medical card number is usually a nine digit number.

What state or entity has issued this medical card?

What is troubling you?

How old is the patient?

What languages can you understand?

What are the sources of medical history?

Where are you located now?

Is your complete medical history ready?
Do you have a physician referral?
Yes
No
Don't know

Who is writing answers to these questions?
The patient.
Someone else on behalf of patient.

If someone else is answering these questions on behalf of the patient, how are you related to the patient?
Sister
Cousin
Brother
Mother
Father
Case manager
Relative
Primary care physician
Nurse
If other, specify.

Have you gone through the Internet human healthcare guidelines? Take a look at this http://www.qureshiuniversity.com/internethealthcareservices.html, public health guidelines, http://www.qureshiuniversity.com/publichealthworld.html patient education guidelines http://www.qureshiuniversity.com/patienteducation.html at mentioned resource?

Do you think your issue or issues have not been answered at this resource and need individualized doctor consultation?

What type of doctor consultation is required?
Ambulatory human health care
Adolescent girls’ consultation
Community health center evaluation
Critical care consultation (anesthesiology)
Coroner investigations
Cardiology consultation
Dermatology consultation
Disability consultation
Dental consultation
Emergency medicine consultation
Endocrinology consultation
Forensic medicine consultation
Gastroenterology consultation
Geriatrics consultation
Hematology consultation
Internet healthcare consultation
Medical negligence consultation
Nephrology consultation
Neurology consultation
Oncology consultation
Ophthalmology consultation
Orthopedics consultation
Otorhinolaryngology consultation
Obstetrics & Gynecology consultation
Primary care physician consultation
Pediatrics consultation
Psychiatry consultation
Pulmonary medicine consultation
Physical medicine & Rehabilitation consultation
Public health guidelines
Radiology & nuclear medicine consultation
Surgical consultation
Women's health consultation

Brain & central nervous system (nervous system)
Circulatory System
Digestive System
Endocrine System
Integumentary system
Lymphatic (immune) system
Muscular system
Reproductive System
Respiratory System
Skeletal System
Urinary system

Impairment Rating and Disability Determination
Health status

How would you describe your health status relevant to your age?
100% mentally fit.
100% physically fit.

Do you have any problems with activities mentioned below relevant to your age?
Walking
Seeing
Hearing
Speaking
Breathing
Learning
Working
Caring for oneself (eating, dressing, toileting, etc.)
Performing manual tasks
Getting started after sleep
Sitting
Sleeping

Face-to-face, in person consultation.

Why are you here today?
What best describes your existing medical conditions?
In the list below you will find many of the most common diseases and pre-existing conditions. ACID REFLUX (GERD)
ADDISON’S DISEASE
ALCOHOL ABUSE AND RECOVERY
ANXIETY
ARTHRITIS
ASTHMA
ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)
AUTISM
BASAL CELL CARCINOMA
BERGER’S DISEASE
BIPOLAR DISORDER
BLOOD CLOT
BREAST CANCER
BRONCHITIS (CHRONIC)
CANCER
CARDIOVASCULAR DISEASE
CHOLESTEROL
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
CONGESTIVE HEART FAILURE (CHF)
CROHN’S DISEASE
DEPRESSION (MAJOR DEPRESSIVE DISORDER, CLINICAL DEPRESSION AND CHRONIC DEPRESSION)
DIABETES TYPE 2
DIABETES TYPE 1
DUI/DWI
DUODENAL ULCER
EMPHYSEMA
EPILEPSY
EROSIVE ESOPHAGITIS
FIBROMYALGIA
GASTRIC ULCER
GASTROESOPHAGEAL REFLUX DISEASE (GERD)
GLAUCOMA
GOUT
HEART ATTACK
HEARTBURN
HEART DISEASE
HEART MURMUR
HEPATITIS
HERPES
HIGH CHOLESTEROL
HYPERTENSION
HYPERTHYROIDISM
HYPOTHYROIDISM
INSOMNIA
KIDNEY STONES
MARIJUANA
MIGRAINES
NARCOLEPSY
NASAL POLYPS
OBSESSIVE COMPULSIVE DISORDER
OSTEOPOROSIS
OVERWEIGHT
PAGET’S DISEASE
PANIC DISORDER
PEPTIC ULCER
PREMENSTRUAL DYSPHORIC DISORDER
POST TRAUMATIC STRESS DISORDER (PTSD)
PROSTATE (ENLARGED)
RESTLESS LEG SYNDROME (RLS)
SCHIZOPHRENIA
SEASONAL AFFECTIVE DISORDER (SAD)
SEIZURES
SLEEP APNEA
SLEEP DISORDERS
STENT (CARDIAC)
STROKE
SQUAMOUS CELL CARCINOMA
THROMBOSIS
TRANSIENT ISCHEMIC ATTACK (TIA)
ULCERS
ZOLLINGER-ELLISON SYNDROME

Did you have any of these medical conditions in the past?

What is a pre-existing medical condition?
Pre existing condition is a medical condition or healthcare problem that existed before enrolling in a healthcare plan.
The "objective standard" of the definition states that a pre-existing condition is anything for which you've received medical advice, care, diagnosis, and treatment prior to your enrollment.
By contrast, the "prudent standard" of the definition states that a pre-existing condition is any condition for which symptoms were present although medical advice, care, diagnosis, or treatment may not have been received prior to enrollment. Under the "prudent standard," an "ordinarily prudent" individual surely would have sought medical advice, care, diagnosis, or treatment for any symptoms that were present prior to enrollment.
Most states implement the prudent standard of the definition.

Here are further guidelines.

Blood Alcohol Concentration (BAC)
What is BAC?
BAC refers to the percent of alcohol in a person's blood stream. A BAC of .10% means that an individual's blood supply contains one part alcohol for every 1000 parts blood.

In ______, a person is legally intoxicated if he/she has a BAC of .08% or higher.

Factors that determine BAC

•Number of standard drinks (see below)
•Amount of time in which drinks are consumed
•Body weight
•Gender
•Race/Ethnicity
•Medications
•Food (to lesser extent)

One standard drink:

•One 12 oz. regular beer (4.5% alcohol)
•One 7 oz. malt liquor (7% alcohol)
•One 4.5 oz. glass of wine (12% alcohol)
•One-third jigger (.5 oz.) of Everclear (95% alcohol)

More than one standard drink:

•One 16 oz. cup of beer = 1.4 drinks
•One 40 oz. beer = 3.6 drinks
•One 22 oz. malt liquor = 3 drinks
•One 12 oz. glass of wine = 2.9 drinks
•One 12 oz. margarita = 2-4 drinks, depending on ingredients
•One 12 oz. cup of trashcan punch = 4-10 drinks, depending on ingredients

How is Blood Alcohol Concentration Determined?

Q: What different methods are used to measure blood alcohol concentration (BAC)? A: There are five different bodily samples that can be screend for a DUI suspect's BAC level: urine, saliva, hair follicles, blood and breath. However, only breath analysis (i.e. breathalyzer) and blood screening are broadly used by law enforcement for gathering evidence. As blood screening is considered more invasive, this method is used less often than breath analysis (mainly after a serious accident or where the suspect has refused a breath test).

Q: How do breathalyzer tests work?

A: There are different machines on the market used for analyzing a DUI suspect's blood alcohol concentration. Some, though rarely used today, employ what is called a "wet chemical" technique to compare one's breath to a sample. The most current generation of breath analysis machines (still commonly referred to as "breathalyzers"), analyze the alcohol content of exhaled vapor through a method called infrared spectroscopic analysis.

The latter method of analysis is based on the scientific principal that captured alcohol vapor absorbs light waves of a particular frequency in the presence of light, depending on the amount of alcohol present. A computer translates this data into the more familiar BAC measurement used to determine the level of alcohol in a person's bloodstream (for example, 0.08 percent BAC).

Q: How accurate are they?

A: While they are not as accurate as blood tests, breathalyzers have been considered acceptably accurate by most courts as tools for gathering evidence. However, some independent studies have determined that breath readings can vary by 15 percent from actual BAC levels (as measured by a blood draw). Some courts have even thrown out breathalyzer results, calling into question the reliability of the machines.

In 1988, a New Jersey court cited the following scientific evidence: (1) high readings for 14 percent of the population due to design flaws; (2) variance in results based on the temperature of the machine itself; (3) different results from the varying body temperatures of test subjects and (4) variances in the presence of hematocrit in the blood also affecting test results. Accuracy also can be hampered by the use of an improperly calibrated machine.

Q: Can you beat a breathalyzer test if you're intoxicated?

A: No. Some popular methods thought to help individuals fool a breathalyzer test, including the ingestion of breath mints, mouthwash, onions and even pennies, have been shown not to work. Mouthwash (which often contains alcohol) may actually have a tendency to raise a person's BAC.

Q: Is it possible to successfully challenge breathalyzer results in court?

A: Absolutely. Breathalyzer machines must be tested routinely to make sure they are properly calibrated. A skilled DUI lawyer will look into the maintenance records of the device used to test his or her client and otherwise determine the validity of the evidence.

Q: How accurate are those small, inexpensive BAC-testing devices sold to consumers?

A: It depends. There is a wide range of products available, some more accurate than others, but it's always best to assume they may be a little off (and they may not be used as as a defense to DUI charges). Saliva alcohol test strips are considered to be among the most accurate consumer BAC tests, since the amount of alcohol in one's bloodstream closely corresponds to the concentration of alcohol in the saliva.

Blood alcohol concentration in an emergency room

Case report of blood alcohol concentration in an emergency room

If blood alcohol concentration results in an emergency room are greater than expected, what should an emergency room physician do?

Here is a case report.
This case report will make you understand.

This happened in Chicago, Illinois, North America, before the year 2004.
A person had never consciously consumed alcohol because of being religious Muslim.
Suddenly, he had an accident. There was no injury but he felt something was wrong and he needed to go to a medical emergency room. He was taken to Swedish Covenant Hospital in Chicago, Illinois.
In the medical emergency room, his blood tests show a high concentration of alcohol.

What negligence was the emergency physician guilty of?

He did not ask him these questions.
He did not verify answers to these questions.

Do you consume alcohol?
No.

Have you ever consciously consumed alcohol?
No.

How did alcohol concentration come up in his blood?
Here are further facts.
Before taking a vehicle, he asked for a glass of water from a restaurant while having a meal near Swedish Covenant Hospital.

Instead of giving him water he was intentionally given alcohol by others so that sabotage occurred and he was harmed. Sabotage occurred due to the accident.
He had never consciously consumed alcohol.
This was a scenario of intentional harms and sabotage against him.

The emergency room physician should have reported this as medicolegal case and that the patient was a victim of sabotage.
What is the best scenario about this case?
The victim or patient in this case was himself an emergency room specialist with seven years of hospital experience at that point.

Urine Drug Test
Screening urine for drugs of abuse in the emergency department: Do test results affect physicians' patient care decisions?

What is a Urine Drug Test?
A urine drug test, also known as a urine drug screen or a UDS, is quick and painless. It tests your urine (pee) for the presence of certain illegal drugs and prescription medications. The urine drug test usually screens for alcohol, amphetamines, benzodiazepines, marijuana, cocaine, and opioids (narcotics).

A urine drug test can catch possible substance abuse problems. Once these problems are identified, doctors can help you start a treatment plan. Urine drug tests throughout the treatment help ensure that the plan is working and that you are no longer taking drugs.

When Is the Test Used?
There are several scenarios where a urine drug test might be ordered.

Your primary care doctor may order this test if he or she suspects you have a problem with drugs or alcohol. An emergency room doctor may also request this test if you are confused and your behavior seems strange or dangerous.

Many Departments in the state require potential workkers to get a urine drug test before hiring them. One benefit of the urine drug screen is that it can be used to keep people with drug problems out of jobs that require the ability to be alert and focused. A drug-addicted air traffic controller or semi-truck driver, for instance, could put the safety of many people at risk.

Drug and alcohol rehabilitation centers test residents on a regular basis. This helps ensure that people receiving treatment for drug or alcohol abuse are staying sober. If you are on probation or parole for a drug- or alcohol-related offense, the officer in charge of your case may request random drug tests to verify sobriety.

Finally, the tests can be used in home settings. For instance, parents may ask teenagers to take this test to prove that they are not using drugs or alcohol. If you are planning to test your teen at home, it’s a good idea to consult with your family doctor or another health professional beforehand. He or she can advise you on how to follow up if the test is positive.

Types of Urine Drug Tests

There are two types of urine drug screens. The first, called the immunoassay, is cost-effective and gives results quickly. However, it has drawbacks. For example, it does not pick up on all opioids (narcotics). Also, it sometimes gives false positives. A false positive occurs when the test results come back positive for drugs, but no drugs have been taken.

If your first test does come back positive, but you deny drug use, you will be given a second type of test: a gas chromatography or a mass spectrometry. The procedure for getting the specimen is no different from the procedure for an immunoassay described above. These tests are more expensive and take longer to give results, but they rarely produce a false positive.

Other weaknesses common to both types of tests include:

•false negatives (the test reports a negative result even if drug use has occurred)
•vulnerability to cheating the system
•failure to capture same-day drug use

How to Take the Test

You may take the urine drug test anywhere a bathroom is available—in a doctor’s office or hospital, a place of business, or at home. The test is carried out as follows:

•The person administering the test will give you a specimen cup.
•You will be required to leave your purse, briefcase, or other belongings in another room while you take the test. You may also be asked to change from your street clothes into a hospital gown. •In some cases, the nurse or technician administering the urine drug screen will accompany you into the bathroom so that you cannot do anything to skew the test results.
•Clean your genital area with a moist cloth that the technician will provide.

•Begin to urinate into the toilet.
•While the urine is in midstream, place the specimen cup in the urine stream. Do not allow the cup to touch your genital area.
•When you have finished urinating, put a lid on the cup and deliver it to the technician.

Urine Drug Test Results

The technician or nurse should be able to inform you of the test results almost immediately. Immunoassays, the most common type of urine drug screening, do not measure drugs themselves. Rather, they measure how drug use interferes with the body’s ability to form antigen-antibody complexes. Results of this test are expressed in ng/mL (nanograms per milliliter). The test is based on a cutoff point so that any number below the cutoff is recorded as a negative screen and any number above the cutoff point is interpreted as a positive screen. The people who are responsible for administering the drug test usually provide results in terms of positive or negative as opposed to numeric values.

Many immunoassay tests do not even display the ng/mL measurements. Rather, the results are shown on a test strip that turns different colors to indicate the presence or absence of various substances. If the results are positive for illegal drugs that you have not taken, you should immediately request a gas chromatography.

Urine drug test case report

What are the possibilities if a urine drug test result is positive?
Prescription drug detection.
Lab error.
Drug abuse.

Here is a case report.

A person is on prescription medication and is asked to take drug test.
Natural prescription medication is detected in the urine.
This is not a case of drug abuse.
This is a case of legal prescription medication detected in urine that is normal.
An incompetent physician secretly tried to report a case of drug abuse, causing embarrassing for all.
This happened in Chicago, Illinois, North America, before 2006.

Criteria for emergency medical services
Who needs emergency medical services?

Do you feel very sick?
Have you been hurt?
Do you know someone else who is been harmed?
Do you think someone else is very sick or has been hurt?
Do you think this situation needs help now within 2-10 minutes?

If yes, you should use emergency medical services.

Is this medical emergency undetermined, good, fair, serious, or critical?
What is the diagnosis?
What is the treatment?

Emergency medicine specialist has to answer these questions.

Criteria for discharge from medical emergency room
1. Vital signs including consciousness: Normal
2. No pain, wounds, or abnormal findings that needs emergency treatment. 3. Glasgow coma scale: 15.
4. Mobility assessment: Normal.
5. Survival needs assessment: Yes.
6. Emotions: Normal relevant to situation.
7. Psychiatric evaluation if required: Normal
8. Relationship Emergency

Emergency diagnosis and treatment and disability assessment are two different assessments. For example, a person can be 100% mentally fit and 95% physically fit.

This is relevant to the individual’s age.
1. Vital signs including consciousness: Normal

Are vital signs including consciousness normal?
Yes.

2. No pain, wounds, or abnormal findings that needs emergency treatment.

3. Glasgow coma scale: 15.

Is Glasgow coma scale 15?
Yes.

4. Mobility assessment

Is individual able to walk or make limb movements relevant to age?
Normal

5. Survival needs assessment.

Does the individual have survival needs form the state?
Yes.

Is it safe for the individual at the residence?

6. Emotions: Anger, sadness, fear, or emotions not relevant to situation needs further evaluation. Normal.

What best describes the individual’s emotions at this point?

Are emotions expression normal relevant to situation?

7. Psychiatric evaluation if required.

Is this individual mentally fit relevant to age?

Advice on discharge from medical emergency room.
This depends on original complaint and diagnosis with relevant treatment.
Treatment depends on the underlying cause.

8. Relationship Emergency

What is a relationship emergency?
Sometimes a relationship emergency is a medicolegal case.
Sometimes a relationship emergency can be without medicolegal issues.

Is everything normal with your family relationships?

Has your relationship become a victim of a criminal conspiracy?
If yes, this is relationship emergency.
It is a medicolegal case.
Where is the women spouse at this point?
Who all are involved in this criminal conspiracy?
No question can remain unanswered.

License Status
What should be included in the license status in the state, outside the state, or internationally in this situation?

Active
Active-probation
Active-provisional
Active-restricted
Administrative error
Approved
Deactivated
Deleted
Denied
Expired
Expired -reapply
Expired-probation
Inactive
Lapsed
Lapsed-probation
Lapsed-provisional
Lapsed-restricted
License in this situation not required
Null and void
Pending
Reinstatement pending
Rescinded provisional license
Revoked
Surrendered
Suspended
Transfer pending
Withdrawn

What are examples of situations in which a license is not required?
Take a look at this.
http://www.qureshiuniversity.com/healthcareworld.html

Who has established these guidelines for emergency medical specialist (first responder) and emergency medicine specialist (medical emergency room)?
Doctor Asif Qureshi
Everything is displayed publicly.
Worldwide healthcare professionals including emergency medical specialists (first responder and emergency room) are scrutinizing these guidelines publicly. License or license renewal is not required in this situation.

Emergency Diagnosis and Treatment
Examples of emergency medical diagnosis and treatment
Here are further guidelines.

Glasgow Coma Scale
Best eye response (E) - 4 grades Spontaneous (4 points)
To verbal command (3 points)
To pain (2 points)
None (1 point)

Score
4
3
2
1
Best Verbal Response (V) - 5 grades Oriented conversation (5 points)
Disoriented conversation (4 points)
Inappropriate words (3 points)
Incomprehensible words (3 points)
Incomprehensible sounds (2 points)
None (1 point)

5
4
3
2
1
Best Motor Response (M) - 6 grades Obeys verbal command (6 points)
Localizes painful stimuli (5 points)
Flexion withdrawl from painful stimuli (4 points)
Decorticate response to painful stimuli (3 points)
Decerebrate response to painful stimuli (2 points)
None (1 point)

6
5
4
3
2
1
15 Points: Normal
3-14 Points: Abnormal
There is a Paediatric Glasgow Coma Scale applicable to infants too young to speak - and the equivalent infant responses are given in the various sections below.
Three types of response are independently assessed and are recorded on an appropriate chart (and the overall score is made by summing the scores).
Best eye response (E) - 4 grades
•No eye opening;
•Opening to response to pain to limbs as above
•Eye opening in response any speech (or shout, not necessarily request to open eyes);
•Spontaneous eye opening.

1 pt - No eye opening
2 pts - Eye opening in response to pain
3 pts - Eye opening in response to speech
4 pts - Spontaneous eye opening
Best Verbal Response (V) - 5 grades
Record best level of speech. If patient is intubated, a "derived verbal score" is calculated via a linear regression prediction.
•No verbal response.
•Incomprehensible speech: Moaning but no words.
Infant: Inconsolable, agitated.
•Inappropriate speech: Random or exclamatory articulated speech, but no conversational exchange. Infant: Inconsistantly inconsolable, moaning.
•Confused conversation: Patient responds to questions in a conversational manner but some disorientation and confusion.
Infant: Cries but consolable, inappropriate interactions.
•Orientated: Patient 'knows who he is, where he is and why, the year, season, and month. Infant: Smiles, orientated to sounds, follows objects, interacts.

UNABLE TO ASSESS (eg Intubated)
1 pt - None
2 pts - Incomprehensible speech
3 pts - Inappropriate speech
4 pts - Confused conversation
5 pts - Orientated
Best Motor Response (M) - 6 grades
Apply varied painful stimulus: trapezius squeeze, earlobe pinch, supraorbital pressure, sternal rub, nail-bed pressure etc:
•No response to pain.
•Extensor posturing to pain: The stimulus causes limb extension (abduction, internal rotation of shoulder, pronation of forearm, wrist extension) - decerebrate posture.
•Abnormal flexor response to pain: Stimulus causes abnormal flexion of limbs (adduction of arm, internal rotation of shoulder, pronation of forearm, wrist flexion - decorticate posture.
•Withdraws to pain: Pulls limb away from painful stimulus.
Infant: withdraws from pain.
•Localizing response to pain: Purposeful movements towards changing painful stimuli is a 'localizing' response.
Infant: withdraws from touch
•Obeying command: The patient does simple things you ask (beware of accepting a grasp reflex in this category).
Infant: moves spontaneously or purposefully

1 pt - No response to pain
2 pts - Extensor posturing to pain
3 pts - Abnormal Flexor response to pain
4 pts - Withdraws to pain
5 pts - Localizing response to pain
6 pts - Obeying commands

Emergency Surgeon and Emergency anesthetist
Why has training for emergency surgeon and emergency anesthetist been mentioned together?
Emergency surgeon and emergency anesthetist services in an operating room are interdependent at a specific time duration and location.

What medical emergency cases go to an emergency surgeon or emergency anesthetist in a hospital operating room?
Out of 1,150 human medical emergencies, only 27 go to an emergency surgeon and/or an emergency anesthetist in operating room.

What are examples of emergency cases that go to an emergency surgeon and/or emergency anesthetist in a hospital operating room?
  1. Abscess

  2. Acute airway obstruction

  3. Acute appendicitis

  4. Acute mesenteric ischemia

  5. Acute subdural hematoma

  6. Acute trauma

  7. Aortic dissection

  8. Bleeding ectopic pregnancy

  9. Bowel obstruction

  10. Cardiac tapenade

  11. Gastrointestinal perforation

  12. Incision wounds that need closure under general anesthesia.

  13. Internal bleeding

  14. Intestinal volvulus

  15. Limb ischemia

  16. Orthopedic Emergencies
      Open Fractures or Joints/Traumatic fractures that need internal fixation under general anesthesia.
      Neurovascular Injuries
      Dislocations
      Septic Joints

  17. Paraphimosis

  18. Peritonitis

  19. Pneumothorax

  20. Priapism

  21. Retained abortion

  22. Retinal detachment

  23. Ruptured aortic aneurysm

  24. Stercoral perforation

  25. Surgical Emergencies in Obstetrics and Gynecology

  26. Testicular torsion

  27. Urinary retention not relieved by catheterization.


What should an emergency surgeon and emergency anesthetist know?
An emergency surgeon and emergency anesthetist should know all types of human diagnosis and treatment in various healthcare settings. Then, he or she should be allowed to manage cases listed after proven expertise.

What has experience revealed up to now?
Experience has shown that an individual who can do an 8-inch incision closing in three layers without knowing about correct human diagnosis and treatment claims to be surgeon specialist. Another individual who can give IV anesthesia with ventilation claims to be an anesthesia specialist without knowing correct human diagnosis and treatment. A technician knows these techniques. These techniques can be learned in 4-6 weeks.

Surgical procedure

Questions to be answered before the surgery.
Questions to be answered in postoperative notes.
Questions to be answered in follow-up consultations.

If the expected procedure or surgery is likely to harm the patient, do not go ahead with surgery. If all the questions are not answered, do not go ahead with surgery.

What is your Email address?
What is the name of the individual who needs doctor consultation?
What is the date of birth of the individual who needs doctor consultation?
What is your mailing address?
What was your mailing address from birth until now?
Where is the patient now?
Where do you live now?
How long have you lived at this address?
How long do you plan to live at this address?
What is your contact information including current mailing address, telephone, e-mail, and any other details, and person to contact in case of emergency? Questions to be answered before the surgery.
Who will do the expected procedure?
What is the expected procedure?
What is the expected date, time, and location of surgery?
What is the diagnosis of the patient?
Who verified the diagnosis of the patient?
What is the profile of the patient’s primary care physician?
How will this procedure help or enhance the life of the patient?
Is the surgery really required?
If surgery is really indicated, these questions must be answered.
Why do you recommend this operation?
What operation are you recommending?
Is there more than one way to do this operation?
Are there alternative to surgery?
What are the details of the operation?
What are the advantages of this operation?
What are the risks of having this operation?
What will happen if this operation is not done?
Who can give a second opinion?
What kind of anesthesia is required?
How long is the operation?
How long will it take to recover from the operation?
How much experience has the doctor had in diagnosing and treating such cases?
How much experience does the doctor have in this specific operation?
Has this type of operation been discussed publicly?
At what hospital will the operation be done?
How long will the doctor be available in the hospital?
Has the surgeon marked the site where he or she will operate with all the preoperative, operative, and postoperative guidelines?
What is the gender of the patient?
What best describes the patient?
Child
Adolescent girl
Adolescent boy
Woman
Man

What best describes the surgery?
Cardiothoracic surgery
Eye surgery
General surgery
Neurosurgery
OB/GYN surgery
Oral and maxillofacial surgery
Orthopedic surgery
Otolaryngology
Pediatric surgery
Plastic surgery
Urology

Is this emergency surgery, urgent surgery, or elective surgery?
What are examples of emergency surgery, urgent surgery, and elective surgery?

Emergency surgery
www.qureshiuniversity.com/emergencysurgery.html

Urgent surgery
href://www.qureshiuniversity.com/urgentsurgery.html

Elective surgery
href://www.qureshiuniversity.com/electivesurgery.html

Questions to be answered in postoperative notes. Here are further guidelines.

Questions to be answered in follow-up consultations.

How did the patient improve or was helped by the specific procedure or surgery?

In general, how is your physical and mental health?
Excellent Good Fair Poor
I have read and agree to the Terms & Conditions.
These are basic questions.
There are many more.
Surgery: Is it really indicated?
A statement mentions that the surgery department lacks equipments and infrastructure.

What type of equipment do you need?
If you audit existing surgeries, you will discover that most of them are not required, and there has been wrong clinical diagnosis.
A diagnosis of appendicitis: on operation, no findings of appendicitis. A diagnosis of cholecystitis or cholelithiasis: on operation, no findings of cholecystitis or cholelithiasis.
A medical doctor is required to make correct clinical diagnoses. A surgeon is basically a medical doctor.
They ask for number of unwanted investigations but after that they still cannot reach a correct diagnosis and treatment.

Q: Who is a surgeon?

A: A surgeon is a medical doctor with additional training in specific medical procedures. Getting the title of surgeon does not mean he or she is a competent medical doctor. Not all surgeons can perform all medical procedures. Not all medical doctors can perform all medical procedures. Making an eight-inch incision and closing in three layers does not prove you are a surgeon or a medical doctor. Doing a burr hole and closing does not prove you are a surgeon. This is a medical or surgical procedure that can be taught in a few weeks. Doing medical or surgical procedures does not prove you are a competent medical doctor.

The ability to reach to a correct diagnosis and provide treatment is a requirement of all medical doctors while maintaining good character and good behavior.
Surgical Skills
What type of suggestions should a medical doctor (MD) forward to improve training programs in health care and medical education?
What do you have to do in case you need to be a surgeon?
What questions should a medical doctor or surgeon ask an anesthetist?
What are the different types of surgery?
What are the surgical specialties?
Neurosurgery
    Q: What is neurosurgery?
    Q: What is a neurosurgeon?
    Q: Who sees a neurosurgeon?
    Q: What might neurological care involve?
    Q: What areas of care are available?
    Q: Who is a neurosurgeon?
    Q: What does neuroscience care involve?
    Q: Where is the neuroscience patient cared for?
    Q: What medical conditions require brain surgery?
    Q: What risks are associated with brain surgery?
    Q: How is brain surgery done?
    Q: What are other names for brain surgery?
    Here are further guidelines.
Cardiothoracic surgery
    Q: Who are usually included in the Cardiovascular Thoracic Surgery Department team?
    Q: What is an MCh in cardiovascular and thoracic surgery?
    Q: How many MCh's in cardiovascular and thoracic surgery are required in the state?
    Q: What skills and knowledge are needed for an MCh in cardiovascular and thoracic surgery?
    Q: What are the duties and responsibilities of a person with an MCh in cardiovascular and thoracic surgery?
    Q: What equipment does cardiovascular and thoracic surgery need?
    Q: What other resources does cardiovascular and thoracic surgery need?
    Here are further guidelines.
Oral and maxillofacial surgery
Otolayrngology
Eye Surgery
OB/GYN Surgery
Paediatric surgery
Plastic Surgery
    How many plastic surgeons are required in the state?
    What specific skills and knowledge should be imparted to plastic surgeons?
    What specific cases do plastic surgeons treat?
    How should plastic surgery research in the state go ahead?
    How many plastic surgery operations were done in the state over the past 10 years?
    What was the diagnosis and treatment?
    How many total cleft lip and cleft palate children have been born in the state over the past 10 years?
    At what were they operated on?
    What was the outcome of the operation?
    How is cleft palate surgery done?
    How is cleft lip surgery done?
Orthopaedic surgery
Urology
General surgery
    Do all cases of appendicitis need surgery?
    Do all cases of cholecystitis or gallstones need surgery?

    Dr. Qureshi's technique

    Q: What are the advantages of laparoscopy?
    A: It is less invasive, cost effective, results in fewer infections, and shorter hospital stay. Also, early return to work, minimal postoperative complications, and cosmetic advantages, too.

    Can appendicitis be managed with endoscopic/Laparoscopy removal without general anesthesia?
    Q: What does the surgeon use to close the wound?
    Q: What is the difference between sutures, staples and Steri-Strips?
    Q: Do all sutures dissolve?
    Q: Is it painful to have sutures and staples removed?
    Q: How is the wound bandaged?
    Q: How should I care for my wound?
    Q: Is it normal for the wound to itch?
    Q: How do I take care of my wound at home?
    Q: When can I take a shower?
    Q: Does it take a long time for the wound to heal?


    Do you have a question?
    Can you make me wiser? How?
    Can you make us wiser? How?
    Would you like to add anything?

    Who among you has done laparoscopic surgery?
    How many surgeries have you done so far?
    What was the diagnosis?
    What were the indications?
    What were the results?
    Were there any post- procedure complications?
    What were these complications?
    What is been done to prevent these complications?
    Who is the manufacturer of the equipment?
    What is the material of the existing equipment?
    What is been done to enhance the efficiency of a laparoscopy?
    What is been done to train others?
    Who has the responsibility to fund this research and development?
Surgical Skills

Do you know various surgical skills?
What are various surgical skills?


What is a surgical technique?
A systematic surgical procedure by which a medical condition is treated.

What questions should you answer in case you introduce new surgical technique?
Is this a new surgical technique or already listed in surgical skills practiced by others on human beings?


New Surgical Technique

Is there any specific name for this new surgical technique?
What is the name of this new surgical technique?
Have you discussed with other doctors the benefits, complications, and harms due to this new surgical technique?
For what type of patients is diagnosis and treatment with this new surgical technique useful?
How is this surgical technique going to improve the condition of the patient?
How is this surgical technique performed, from beginning to end?
For what medical condition is this surgical technique the only option of treatment?
What issues is this medical condition causing the patient?
What complications can occur due to this surgical technique?

Why was there a need to elaborate on these facts?

On September 12, 2013, Department of Surgical Gastroenterology SKIMS started sophisticated pancreatic surgery, pancreaticoduodenectomy with portal venous resection and later reconstruction. A team of surgeons headed by Prof. Omar Javed Shah was the first of its kind in Kashmir.
The above questions were not answered in the academic deliberations.


General anesthesia skills
How long will it take you to learn general anesthesia skills?
Maximum six months if you have desire to learn.

Who should learn general anesthesia skills?
Anesthetist
Emergency medical specialist who occasionally has to practice these skills.

What should you know about general anesthesia as an anesthetist or medical specialist?
Preoperative assessment
Premedication
Induction
Airway management
Maintenance of anesthetic
Complications
Recovery
Safety
Historical perspective
References
Premedication

What premedication is used before surgery?
Temazepam generally is given 30 minutes to 2 hours before surgery.
Midazolam is used in the anaesthetic room, both as an anxiolytic and to reduce the amount of induction agent used.

Drugs also may be used to reduce gastric acidity - generally ranitidine but sometimes sodium citrate for rapid sequence pre-induction.

IV induction.

What are the types of IV induction?
Sodium thiopentone was commonly used until recently. Today, propofol and fentanyl or alfentanil are often used. This is followed by use of a laryngeal mask airway (LMA) or an ordinary BOC mask (all sized appropriately).

Inhalational induction

Inhalational induction uses a volatile anesthetic such as sevoflurane to induce anaesthesia over 3-5 minutes, followed by either placement of an LMA or muscle relaxant and intubation.

Sevoflurane has superseded isoflurane, halothane, and others as the agent of choice for inhalational induction of anaesthesia because it has a more rapid onset of action. The patient maintains his/her own airway as anesthesia progresses; thus, if there are difficult airway issues, laryngoscopy can be performed with the patient still breathing.

Fentanyl or alfentanil are normally given at induction to obtund the stress response from direct laryngoscopy.

Other available
Suxamethonium
Rocuronium
Maintenance of anaesthetic

What are aims of general anaesthesia?

Controlled unconsciousness.
Pain relief.
Muscle relaxation.
Reducing the response of the autonomic nervous system.

How are these aims of general anaesthesia achieved?
How should monitoring be done during anaesthesia?
What are the complications of general anaesthesia?
How long does it take to recover from anaesthesia?
What types of intravenous anaesthesia are available in the hospital?
What types of inhalation anaesthesia are available in the hospital?
How many emergency surgeons and emergency anesthetists are there in the state?
How many intensivists for intensive care units are there in the state? Here are further guidelines.

Controlled unconsciousness is due to general anesthesia.

Intensivist
What medical emergency cases go to the intensive care unit in a hospital?
Out of 1,150 human medical emergencies, 18 of them go to a hospital’s intensive care unit.

What are examples of emergency cases that go to Intensive care unit in a hospital?

http://www.qureshiuniversity.com/criticalcareworld.html

Director of the state emergency medical services
Questions you need to answer.

How many emergency medicine specialists (first responder) and emergency medicine specialists (Medical Emergency room) are there in the state?
Where is their biodata publicly displayed?





Emergency Medicine Specialist Training Programs
Emergency Medical Services
State Department of Emergency Medicine
Emergency Medical Services Training Programs
For whom are these Emergency Medical Services Training Programs meant?
  1. Emergency medicine specialist (first responder)

  2. Emergency medicine specialist (medical emergency room)

  3. Emergency Surgeon and Emergency anesthetist

  4. Guide for emergency medicine specialist

  5. Emergency medical dispatcher

  6. Emergency medicine specialist (dispatcher)

  7. Senior emergency medical specialist

  8. Director of the state emergency medical services

  9. Director of the state department of public health

  10. Secretary of the state department of health

  11. Governor of the state and role in state emergency medical services

  12. Emergency paramedic (First responder)

  13. Emergency paramedic (emergency room)

  14. Emergency medical technician (first responder)

  15. Emergency medical technician (emergency room)

  16. Intensivist

  17. Nurse (emergency room)

  18. Ambulance operator

  19. Inventory accountant in the state.

Why was there a need to establish these guidelines?
Human healthcare in various states including emergency medical services in various states, is shambles, and substandard.
Shambles means badly organized and does not operate effectively.
Substandard means not as good as you would normally expect, or not good enough to be accepted.

Unconsciousness at a public location.
Sudden unconsciousness at home.
What is unconsciousness?
Unconsciousness means being unable to see, hear, and talk.
Often, this is called a coma or being in a comatose condition.
An unconsciousness person will be unresponsive to activity, touch, sound, or other stimulation. He or she will not be able to communicate and won’t respond to stimulation.

Conscious means able to see, hear, and talk.
In pediatric patients younger than six months of age, the ability to make any verbal noise or cry is equivalent to talking.

A person may be unconscious for a few seconds (as is the case with fainting) or for longer periods of time.

What are the causes of unconsciousness?
Alcohol use.
Drowning.
Electric shock
Substance abuse
Severe blood loss
8 H's and 6 T's: mnemonic for mechanisms
Hypoxia
Hypovolemia
Hyperkalemia
Hypokalemia
Hypoglycemia
Hypothermia
Hyperthermia (heat stroke)
Hydrogen ions (acidosis)
Thrombosis (MI/heart attack)
Tension pneumothorax
Tamponade
Toxins/therapeutics
Thromboembolism
Trauma

What is the difference between being asleep and being unconscious?
Being asleep is not the same thing as being unconscious.
A sleeping person will respond to loud noises or gentle shaking; an unconscious person will not.

An unconscious person cannot cough or clear his or her throat. This can lead to death if the airway becomes blocked.

Is there a difference between unconsciousness and cardiopulmonary arrest?
Yes.

What is the difference between unconsciousness and cardio pulmonary arrest?
Unconsciousness is usually without cardiac arrest.
If unconsciousness is associated with cardiac arrest or respiratory arrest, cardiopulmonary resuscitation is required.

What is Basic Life Support (BLS)?
Basic Life Support (BLS) refers to the act of supporting an unconscious patient's breathing and circulation in order to preserve their life and buy time for professional emergency medical attention.

What should you know about basic life support?
Basic life support is meant for an unconscious patient.
All unconscious patients need basic life support.
Not all unconscious patients need cardiopulmonary resuscitation (breathing support, chest compressions).
Only unconscious patients with cardiac arrest or respiratory arrest need cardiopulmonary resuscitation including breathing support and chest compressions).

Does the unconscious patient need basic life support with CPR or without CPR?

If the unconscious patient needs basic life support with cardiopulmonary resuscitation with chest compressions here are further guidelines.
Cardiopulmonary resuscitation guidelines.

Unconscious patient.

What type of patient needs basic life support?
An unconscious patient.

Do all unconscious patients need cardiopulmonary resuscitation?
No.

How should you evaluate and treat an unconscious patient?
Assessment is very important.
Not all unconscious patients need cardiopulmonary resuscitation.

When do you start cardiopulmonary resuscitation in adults?
CPR is required someone's breathing or heartbeat has stopped, as in cases of electric shock, drowning, or heart attack.
CPR is a lifesaving procedure in this situation.

What is cardiopulmonary resuscitation?
Cardiopulmonary resuscitation is a combination of rescue breathing and chest compressions.
Rescue breathing provides oxygen to a person's lungs.
Chest compressions keep the person's blood circulating.
Permanent brain damage or death can occur within minutes if a person's blood flow stops. Therefore, you must continue these procedures until the person's heartbeat and breathing return, or trained medical help arrives.

In what situations is a directive like "Do not Resuscitate" justified?
Old age more than 95 years with known complications.

Here are further guidelines.

Survival needs monitoring
Deprivation of human survival needs (not having human survival needs):Is it an emergency?
Yes, it is.

Do you know whether the deprivation of human survival needs is a criminal offense?
Do you know whether the deprivation of human survival needs (not having survival needs) is a medical emergency/administrative emergency?

What is the deprivation of human survival needs (not having human survival needs)?
What are basic/normal human survival needs?

1. Water
2. Food
3. Building needs
4. Everyday sleeping/living location
5. Healthcare
6. Clothes
7. Transportation
8. Safety
9. Education (a lack of education leads to long-term consequences)
10. Caregiver
11. Communication(etc.)
12. Air (oxygen)
The deprivation of human survival needs (not having human survival needs): Is it a medical emergency, an administrative emergency, or both?

Medical history relevant to this medical condition

Has the person been provided essential survival needs?
Does the person need any help in getting survival needs?
What are the details of the survival needs of the person?


Who has a duty to provide the basic human survival needs?
The state of which a person is a resident has a duty to provide for the survival needs for the person.

Ocean-going vessels and aircrafts in the atmosphere are connected to a specific state. That state has a duty to arrange for the survival needs regardless of the actual location of the vessels.

Is the deprivation of human survival needs (not having human survival needs) a public health issue?
Yes, it is.

Do basic human rights and human survival needs refer to the same idea?
Yes, they do.

What should you do if you do not have survival needs?
Cal 211; make a statement: I do not have survival needs.

Prevention

How can this medical emergency/situation be prevented?
Through the state's proper administration.
The second, third, fourth, and fifth in command should always be ready to take over administration of the state in case the existing governor is incompetent or becomes influenced to do harm.

How should the distribution of human survival needs in every state progress?
http://www.qureshiuniversity.com/humanservicesworld.html

Survival needs monitoring

Who has the duty to provide and monitor survival needs of residents in the state?
The state department of human services.
The state department of food and supplies.
The state department of law.
The state department of defense.
Other similar departments in the state.

What will happen if the survival needs of residents are not properly provided and monitored in the state?
Acute stress reaction.
Starvation.
Dehydration.
Malnutrition.
Premature death.
Other harms.

What concept of law is applicable to this situation?
Human rights violation.
Failure to provide necessities.
Deprivation of rights under the color of law.
Exclusion.
Other harms.

How should you monitor survival needs of residents in the state?
Circulate relevant questions to the residents.

What are the sources of your survival needs?
The state department of human services.
The state department of food and supplies.
Etc.

What best describes your survival needs for the one year from January 1, 2015, to January 1, 2016?
1. Water
2. Food
3. Building needs
4. Everyday sleeping/living location
5. Health care
6. Clothes
7. Transportation
8. Safety
9. Education (a lack of education leads to long-term consequences)
10. Caregiver
11. Communication (etc.)
12. Air (oxygen) (Properly ventilated living room/Not properly ventilated living room)

What options can you add to each survival need?
1. Enough
2. Not enough
3. Need more
4. I do not have survival needs from the state for the next 24 hours or one month. This is an emergency.
In various regions, specific numbers have been displayed to call if you do not have survival needs.

What number should an individual call if the individual does not have survival needs in the state for next 24 hours or the next one month?
http://www.qureshiuniversity.com/justiceworld.html

You can update the relevant date every year.

These are monitoring details for survival needs.
Harms and other health care monitoring issues have other details.

Here are further guidelines.

Here are further guidelines.
http://www.qureshiuniversity.com/survivalneeds.html

Adult
Basic Life Support
What is Basic Life Support (BLS)?
Basic Life Support (BLS) refers to the act of supporting an unconscious patient's breathing and circulation in order to preserve their life and buy time for professional emergency medical attention.

What should you know about basic life support?
Basic life support is meant for an unconscious patient.
All unconscious patients need basic life support.
Not all unconscious patients need cardiopulmonary resuscitation (breathing support, chest compressions).
Only unconscious patients with cardiac arrest or respiratory arrest need cardiopulmonary resuscitation including breathing support and chest compressions).

Does the unconscious patient need basic life support with CPR or without CPR?

If the unconscious patient needs basic life support with cardiopulmonary resuscitation with chest compressions here are further guidelines.
Cardiopulmonary resuscitation guidelines.

Unconscious patient.

What type of patient needs basic life support?
An unconscious patient.

Do all unconscious patients need cardiopulmonary resuscitation?
No.

How should you evaluate and treat an unconscious patient?
Assessment is very important.
Not all unconscious patients need cardiopulmonary resuscitation.

When do you start cardiopulmonary resuscitation in adults?
CPR is required someone's breathing or heartbeat has stopped, as in cases of electric shock, drowning, or heart attack.
CPR is a lifesaving procedure in this situation.

What is cardiopulmonary resuscitation?
Cardiopulmonary resuscitation is a combination of rescue breathing and chest compressions.
Rescue breathing provides oxygen to a person's lungs.
Chest compressions keep the person's blood circulating.
Permanent brain damage or death can occur within minutes if a person's blood flow stops. Therefore, you must continue these procedures until the person's heartbeat and breathing return, or trained medical help arrives.

In what situations is a directive like "Do not Resuscitate" justified?
Old age more than 95 years with known complications.

What is unconsciousness?
Unconsciousness means being unable to see, hear, and talk.
Often, this is called a coma or being in a comatose condition.
An unconsciousness person will be unresponsive to activity, touch, sound, or other stimulation. He or she will not be able to communicate and won’t respond to stimulation.

Conscious means able to see, hear, and talk.
In pediatric patients younger than six months of age, the ability to make any verbal noise or cry is equivalent to talking.

A person may be unconscious for a few seconds (as is the case with fainting) or for longer periods of time.

What are the causes of unconsciousness?
Alcohol use.
Drowning.
Electric shock
Substance abuse
Severe blood loss
8 H's and 6 T's: mnemonic for mechanisms
Hypoxia
Hypovolemia
Hyperkalemia
Hypokalemia
Hypoglycemia
Hypothermia
Hyperthermia (heat stroke)
Hydrogen ions (acidosis)
Thrombosis (MI/heart attack)
Tension pneumothorax
Tamponade
Toxins/therapeutics
Thromboembolism
Trauma

What is the difference between being asleep and being unconscious?
Being asleep is not the same thing as being unconscious.
A sleeping person will respond to loud noises or gentle shaking; an unconscious person will not.

An unconscious person cannot cough or clear his or her throat. This can lead to death if the airway becomes blocked.

Is there a difference between unconsciousness and cardiopulmonary arrest?
Yes.

What is the difference between unconsciousness and cardio pulmonary arrest?
Unconsciousness is usually without cardiac arrest.
If unconsciousness is associated with cardiac arrest or respiratory arrest, cardiopulmonary resuscitation is required. Here are further guidelines.

Bag-mask ventilation

Bag-mask ventilation is a basic but critical airway management skill. It enables clinicians to provide adequate ventilation for patients requiring airway support and allows enough time to establish a more controlled approach to airway management, such as endotracheal (ET) intubation. Because the technique can be difficult to perform correctly, clinicians performing the procedure should continually practice and monitor their technique.

Successful bag-mask ventilation depends on three things:
Patent airway. Airway patency can be established using airway maneuvers and airway conduits described above.

Adequate mask seal. In order to secure a good seal, the mask must be placed and held correctly. Disposable bag-mask units are often packaged with one large adult-sized mask. Even though facial anatomy differs for eachpatient, one sized face mask is usually sufficient for positive pressure ventilation with the bag mask. The nasal portion of the mask should be spread slightly and placed on the bridge of the patient's nose. The body of the mask is then placed onto the patient's face covering the nose and mouth. The provider's wrists or the mask cushion should not rest on the patient's eyes during bag-mask ventilation. There are two methods for holding the mask in place. The two-hand mask hold is most effective, however it requires a second clinician. Therefore, the clinician should be comfortable with both techniques.

Proper ventilation (ie, proper volume, rate, and cadence). The three key errors to avoid when performing bag-mask ventilation are:
Excessive tidal volumes: A volume just large enough to cause chest rise (no more than 8 to 10 cc/kg) should be used. During cardiopulmonary resuscitation (CPR), even smaller tidal volumes are adequate (5 to 6 cc/kg) due to the reduced cardiac output of such patients. Forcing air too quickly: The bag should not be squeezed explosively. It should be squeezed steadily over approximately one full second.

Ventilating too rapidly. The ventilatory rate should not exceed 10 to 12 breaths per minute.

BLS training is intended for certified or noncertified, licensed or nonlicensed, healthcare professionals, including:
•physicians
•nurses
•paramedics
•emergency medical technicians
•respiratory, physical, and occupational therapists
•physician's assistants
•residents or fellows
•medical or nursing students in training
•aides, medical or nursing assistants, and other allied health personnel
In addition, BLS training can be appropriate for first responders, such as police officers and firefighters, as well as for laypeople whose work brings them into contact with members of the public, such as school, fitness center, or other employees.

Airway

Is the airway open?
Does the patient need an advanced airway?

Breathing

Is oxygenation and ventilation sufficient?
If used, is the airway device properly placed and monitored?
Are CO2 and O2 sats being monitored?

Circulation

What is the current cardiac rhythm?
Is IV/IO access obtained?
Does the patient need fluids or medications?

Is a heart attack the same as cardiac arrest?
No.

What is a heart attack?
A heart attack occurs when a blocked artery prevents oxygen-rich blood from reaching a section of the heart. If the blocked artery is not reopened quickly, the part of the heart normally nourished by that artery begins to die. The longer a person goes without treatment, the greater the damage. Symptoms of a heart attack may be immediate and intense. More often, though, symptoms start slowly and persist for hours, days or weeks before a heart attack. Unlike with sudden cardiac arrest, the heart usually does not stop beating during a heart attack. The heart attack symptoms in women can be different than men.

What is cardiac arrest?
Cardiac arrest is the abrupt loss of heart function in a person who may or may not have diagnosed heart disease.

What to do: Sudden Cardiac Arrest

Cardiac arrest is reversible in most victims if it's treated within a few minutes. First, call ________ for emergency medical services. Then get an automated external defibrillator if one is available and use it as soon as it arrives. Begin CPR immediately and CONTINUE until professional emergency medical services arrive. If two people are available to help, one should begin CPR immediately while the other calls ______ and finds an AED.

Differential Diagnosis

Why did arrest occur?
Are there any other factors?
Can we reverse the cause(s)?
7 H's and 5 T's: mnemonic for mechanisms
•hypoxia
•hypovolemia
•hyperkalemia
•hypokalemia
•hypoglycemia
•hypothermia
•hydrogen ions (acidosis)
•thrombosis (MI/heart attack)
•tension pneumothorax
•tamponade
•toxins/therapeutics
•thromboembolism
•trauma

Hypovolemia

Hypovolemia or the loss of fluid volume in the circulatory system can be a major contributing cause to cardiac arrest. Looking for obvious blood loss in the patient with pusleless arrest is the first step in determining if the arrest is related to hypovolemia. After CPR, the most import intervention is obtaining intravenous access/IO access. A fluid challenge or fluid bolus may also help determine if the arrest is related to hypovolemia.

Hypoxia

Hypoxia or deprivation of adequate oxygen supply can be a significant contributing cause to cardiac arrest. You must ensure that the patient’s airway is open, and that the patient has chest rise and fall and bilateral breath sounds with ventilation. Also ensure that your oxygen source is connected properly.

Hydrogen ion (acidosis)

To determine if the patient is in respiratory acidosis, an arterial blood gas evaluation must be performed. Prevent respiratory acidosis by providing adequate ventilation. Prevent metabolic acidosis by giving the patient sodium bicarbonate.

Hyper-/hypokalemia

Both a high potassium level and a low potassium level can contribute to cardiac arrest. The major sign of hyperkalemia or high serum potassium is taller and peaked T-waves. Also, a widening of the QRS-wave may be seen. This can be treated in a number of ways which include sodium bicarbonate (IV), glucose+insulin, calcium chloride (IV), Kayexalate, dialysis, and possibly albuterol. All of these will help reduce serum potassium levels.

The major signs of hypokalemia or low serum potassium are flattened T-waves, prominent U-waves, and possibly a widened QRS complex. Treatment of hypokalemia involves rapid but controlled infusion of potassium. Giving IV potassium has risks. Always follow the appropriate infusion standards. Never give undiluted intravenous potassium.

Hypoglycemia

Hypoglycemia or low serum blood glucose can have many negative effects on the body, and it can be associated with cardiac arrest. Treat hypoglycemia with IV dextrose to reverse a low blood glucose. Hypoglycemia was removed from the H’s but is still to be considered important during the assessment of any person in cardiac arrest.

Hypothermia

If a patient has been exposed to the cold, warming measures should be taken. The hypothermic patient may be unresponsive to drug therapy and electrical therapy (defibrillation or pacing). Core temperature should be raised above 86 F (30 C) as soon as possible.

The T’s include:

Toxins

Accidental overdose of a number of different kinds of medications can cause pulseless arrest. Some of the most common include: tricyclics, digoxin, betablockers, and calcium channel blockers). Street drugs and other chemicals can precipitate pulseless arrest. Cocaine is the most common street drug that increases incidence of pulseless arrest. ECG signs of toxicity include prolongation of the QT interval. Physical signs include bradycardia, pupil symptoms, and other neurological changes. Support of circulation while an antidote or reversing agent is obtained is of primary importance. Poison control can be utilized to obtain information about toxins and reversing agents.

Tamponade

Cardiac tamponade is an emergency condition in which fluid accumulates in the pericardium (sac in which the heart is enclosed). The buildup of fluid results in ineffective pumping of the blood which can lead to pulseless arrest. ECG symptoms include narrow QRS complex and rapid heart rate. Physical signs include jugular vein distention (JVD), no pulse or difficulty palpating a pulse, and muffled heart sounds due to fluid inside the pericardium. The recommended treatment for cardiac tamponade is pericardiocentesis.

Tension Pneumothorax

Tension pneumothorax occurs when air is allowed to enter the plural space and is prevented from escaping naturally. This leads to a build up of tension that causes shifts in the intrathroacic structure that can rapidly lead to cardiovascular collapse and death. ECG signs include narrow QRS complexes and slow heart rate. Physical signs include JVD, tracheal deviation, unequal breath sounds, difficulty with ventilation, and no pulse felt with CPR. Treatment of tension pneumothorax is needle decompression.

Thrombosis (heart: acute, massive MI)

Coronary thrombosis is an occlusion or blockage of blood flow within a coronary artery caused by blood that has clotted within the vessel. The clotted blood causes an acute myocardial infarction which destroys heart muscle and can lead to sudden death depending on the location of the blockage.

ECG signs during PEA indicating coronary thrombosis include ST-segment changes, T-wave inversions, and/or Q waves. Physical signs include: elevated cardiac markers on lab test.

Treatments for coronary thrombosis before cardiac arrest include use of fibrinolytic therapy, or PCI (percutaneous coronary intervention). The most common PCI procedure is coronary angioplasty with or without stent placement.

Thrombosis (lungs: massive pulmonary embolism)

Pulmonary thrombus or pulmonary embolism (PE) is a blockage of the main artery of the lung which can rapidly lead to respiratory collapse and sudden death. ECG signs of PE include narrow QRS Complex and rapid heart rate. Physical signs include no pulse felt with CPR. distended neck veins, positive d-dimer test, prior positive test for DVT or PE. Treatment includes surgical intervention (pulmonary thrombectomy) and fibrinolytic therapy.

Trauma

The final differential diagnosis of the H’s and T’s is trauma. Trauma can be a cause of pulseless arrest, and a proper evaluation of the patients physical condition and history should reveal any traumatic injuries. Treat each traumatic injury as needed to correct any reversible cause or contributing factor to the pulseless arrest. Trauma was removed from the T’s but is still to be considered important during the assessment of any person in cardiac arrest. ..

Respiratory Arrest

In respiratory arrest, a pulse is present, though breathing is absent or ineffective.

Perform BLS.

Give one breath every 5-6 seconds, or 10-12 per minute.

Check pulse (quickly) every two minutes.

Stopping Recuscitation

Each patient case is unique, and while clinical rules are developed, the decision to stop CPR is a complex one. Except in specific circumstances, such as hypothermia or drug overdose, BLS or ACLS are very unlikely to be successful after 20 minutes.

Advanced Life Support (ALS)

What is Advanced Life Support?
Advanced cardiac life support (ACLS) describes the treatment of life-threatening cardiac rhythms. ACLS may only be provided by trained experts, as it includes advanced ECG diagnostics, procedural skills, and use of medications. It builds upon basic life support, or CPR, and the use of automated external defibrillators (AEDs). Basic Life Support Ambulance

Basic Life Support care requires medical monitoring by a licensed EMT-Intermediate and may include monitoring vital signs, oxygen and IV therapy. The BLS Ambulance is equipped with state-of-the-art equipment including an automatic external defibrillator, blood pressure monitoring equipment, pulse oximetry and oxygen delivery devices.

Advance Life Support Ambulance

Advanced Life Support care requires medical monitoring and care by a licensed EMT-Paramedic and may include monitoring vital signs, advanced drug therapy, cardiac monitoring, oxygen and IV therapy. The ALS Ambulance is equipped with state-of-the-art heart and blood pressure monitoring equipment, pulse oximetry, IV pumps, oxygen delivery devices including a CPAP and advanced medications used to treat a variety of illnesses and provide pain relief.

The Advanced Life Support team is composed of three members namely: the regular paramedic, the critical care paramedic and the emergency care practitioner.

Here are further guidelines.

Here are further guidelines.

Pediatric Basic and Advanced Life Support

Medical Diagnoses: Ineffective tissue perfusion (cardiac, renal, cerebral).
Signs of inadequate tissue perfusion
Depressed mental status
Decreased urine output
Metabolic acidosis
Tachypnea
Weak central pulses
Deterioration in color such as mottling
Hypotension

Hypotension
Age Hypotensive Systolic Blood Pressure
0-28 days <60mmHg in term neonates
1-12 months <70mmHg in Infants
1-10 years <70mmHg + (2x age in years) in children 1-10
Greater than 10 yrs <90mmHg in children older than 10

Paramedic (EMT-P)
Critical Care Paramedic (CCEMTP)
Emergency Care Practitioner (ECP)
Paramedics are licensed individuals who can perform tasks beyond that of an EMT.

Human Vital Signs
What should you include in Human vital signs?
What are vital signs?
What is body temperature?
What is the pulse rate?
What is the respiration rate?
What is blood pressure?
What special equipment is needed to measure blood pressure?
  • 1. Consciousness

  • 2. Pulse rate

  • 3. Blood pressure

  • 4. Respiration rate

  • 5. Body temperature

  • 6. Emotion
  • In some regions of the world, medical guidelines/medical doctors do not focus on consciousness, thus reaching wrong diagnosis and treatment.
    Is the patient conscious, oriented in time, space, and person?
    Conscious means able to see, hear, and talk.
    In pediatric patients younger than six months of age, the ability to make any verbal noise or cry is equivalent to talking.
    Age-Appropriate Vital Signs
    Ref: Pediatric Vital Signs

    What is the normal respiratory rate for a newborn, infant, toddler, preschooler, school age child, and adolescent?
    What is the normal pulse rate for a newborn, infant, toddler, preschooler, school age child, and adolescent?
    What is the lower limit of normal systolic blood pressure in a newborn, infant, toddler, preschooler, school age child, and adolescent?
    Vital Signs (Body Temperature, Pulse Rate, Respiration Rate, Blood Pressure)

    What are vital signs?

    Vital signs are measurements of the body's most basic functions. The four main vital signs routinely monitored by medical professionals and healthcare providers include the following:
    v * body temperature
    * pulse rate
    * respiration rate (rate of breathing)
    * blood pressure (Blood pressure is not considered a vital sign, but is often measured along with the vital signs.)

    Vital signs are useful in detecting or monitoring medical problems. Vital signs can be measured in a medical setting, at home, at the site of a medical emergency, or elsewhere.

    What is body temperature?

    The normal body temperature of a person varies depending on gender, recent activity, food and fluid consumption, time of day, and, in women, the stage of the menstrual cycle. Normal body temperature, according to the American Medical Association, can range from 97.8° F (or Fahrenheit, equivalent to 36.5° C, or Celsius) to 99° F (37.2° C). A person's body temperature can be taken in any of the following ways:

    What is fever?

    Fever (also called pyrexia) is defined as body temperature that is higher than normal for each individual. It generally indicates that there is an abnormal process going on within the body. The severity of a condition is not necessarily reflected by the degree of fever. For example, influenza may cause a fever of 104° F, while pneumonia may cause a very low-grade fever or no fever at all. Consult with your physician if you have any questions about whether a fever is significant.

    * orally

    Temperature can be taken by mouth using either the classic glass thermometer, or the more modern digital thermometers that use an electronic probe to measure body temperature.

    * rectally

    Temperatures taken rectally (using a glass or digital thermometer) tend to be 0.5 to 0.7° F higher than when taken by mouth.

    * axillary

    Temperatures can be taken under the arm using a glass or digital thermometer. Temperatures taken by this route tend to be 0.3 to 0.4° F lower than those temperatures taken by mouth.

    * by ear

    A special thermometer can quickly measure the temperature of the ear drum, which reflects the body's core temperature (the temperature of the internal organs).

    Body temperature may be abnormal due to fever (high temperature) or hypothermia (low temperature). A fever is indicated when body temperature rises above 98.6° F orally or 99.8° F rectally, according to the American Medical Association. Hypothermia is defined as a drop in body temperature below 95° F.

    About glass thermometers containing mercury:

    According to the Environmental Protection Agency (EPA), mercury is a toxic substance that poses a threat to the health of humans, as well as to the environment. Because of the risk of breaking, glass thermometers containing mercury should be removed from use and disposed of properly in accordance with local, state, and federal laws. Contact your local health department, waste disposal authority, or fire department for information on how to properly dispose of mercury thermometers.

    What is the pulse rate?

    The pulse rate is a measurement of the heart rate, or the number of times the heart beats per minute. As the heart pushes blood through the arteries, the arteries expand and contract with the flow of the blood. Taking a pulse not only measures the heart rate, but also can indicate the following:

    * heart rhythm
    * strength of the pulse

    The normal pulse for healthy adults ranges from 60 to 100 beats per minute. The pulse rate may fluctuate and increase with exercise, illness, injury, and emotions. Females ages 12 and older, in general, tend to have faster heart rates than do males. Athletes, such as runners, who do a lot of cardiovascular conditioning, may have heart rates near 40 beats per minute and experience no problems. Illustration demonstrating how to take a pulse Click Image to Enlarge

    How to check your pulse:

    As the heart forces blood through the arteries, you feel the beats by firmly pressing on the arteries, which are located close to the surface of the skin at certain points of the body. The pulse can be found on the side of the lower neck, on the inside of the elbow, or at the wrist. When taking your pulse:

    * Using the first and second fingertips, press firmly but gently on the arteries until you feel a pulse.
    * Begin counting the pulse when the clock's second hand is on the 12.
    * Count your pulse for 60 seconds (or for 15 seconds and then multiply by four to calculate beats per minute).
    * When counting, do not watch the clock continuously, but concentrate on the beats of the pulse.
    * If unsure about your results, ask another person to count for you.

    If your physician has ordered you to check your own pulse and you are having difficulty finding it, consult your physician or nurse for additional instruction. What is the respiration rate?

    The respiration rate is the number of breaths a person takes per minute. The rate is usually measured when a person is at rest and simply involves counting the number of breaths for one minute by counting how many times the chest rises. Respiration rates may increase with fever, illness, and with other medical conditions. When checking respiration, it is important to also note whether a person has any difficulty breathing.

    Normal respiration rates for an adult person at rest range from 15 to 20 breaths per minute. Respiration rates over 25 breaths per minute or under 12 breaths per minute (when at rest) may be considered abnormal. What is blood pressure?

    Blood pressure, measured with a blood pressure cuff and stethoscope by a nurse or other healthcare provider, is the force of the blood pushing against the artery walls. Each time the heart beats, it pumps blood into the arteries, resulting in the highest blood pressure as the heart contracts. One cannot take his/her own blood pressure unless an electronic blood pressure monitoring device is used. Electronic blood pressure monitors may also measure the heart rate, or pulse.

    Two numbers are recorded when measuring blood pressure. The higher number, or systolic pressure, refers to the pressure inside the artery when the heart contracts and pumps blood through the body. The lower number, or diastolic pressure, refers to the pressure inside the artery when the heart is at rest and is filling with blood. Both the systolic and diastolic pressures are recorded as "mm Hg" (millimeters of mercury). This recording represents how high the mercury column is raised by the pressure of the blood.

    High blood pressure, or hypertension, directly increases the risk of coronary heart disease (heart attack) and stroke (brain attack). With high blood pressure, the arteries may have an increased resistance against the flow of blood, causing the heart to pump harder to circulate the blood.

    According to the National Heart, Lung, and Blood Institute _______ of the National Institutes of Health (NIH), high blood pressure for adults is defined as:

    * 140 mm Hg or greater systolic pressure and
    * 90 mm Hg or greater diastolic pressure

    In an update of ______-guidelines for hypertension in 2003, a new blood pressure category was added called prehypertension:

    * 120 mm Hg – 139 mm Hg systolic pressure and
    * 80 mm Hg – 89 mm Hg diastolic pressure

    The new NHLBI guidelines now define normal blood pressure as follows:

    * Less than 120 mm Hg systolic pressure and
    * Less than 80 mm Hg diastolic pressure

    These numbers should be used as a guide only. A single elevated blood pressure measurement is not necessarily an indication of a problem. Your physician will want to see multiple blood pressure measurements over several days or weeks before making a diagnosis of hypertension (high blood pressure) and initiating treatment. A person who normally runs a lower-than-usual blood pressure may be considered hypertensive with lower blood pressure measurements than 140/90.

    Why should I monitor my blood pressure at home?

    For persons with hypertension, home monitoring allows your physician to monitor how much your blood pressure changes during the day, and from day to day. This may also help your physician determine how effectively your blood pressure medication is working.

    What special equipment is needed to measure blood pressure?

    Either an aneroid monitor, which has a dial gauge and is read by looking at a pointer, or a digital monitor, in which the blood pressure reading flashes on a small screen, can be used to measure blood pressure.

    About the aneroid monitor:

    The aneroid monitor is less expensive and easier to manage than the digital monitor. The cuff is inflated by hand by squeezing a rubber bulb. Some units even have a special feature to make it easier to put the cuff on with one hand. However, the unit can be easily damaged and become less accurate. Because the person using it must listen for heartbeats with the stethoscope, it may not be appropriate for the hearing-impaired.

    About the digital monitor:

    The digital monitor is automatic, with the measurements appearing on a small screen. Because the recordings are easy to read, this is the most popular blood pressure measuring device. It is also easier to use than the aneroid unit, and since there is no need to listen to heartbeats through the stethoscope, this is a good device for hearing-impaired patients. One disadvantage is that body movements or an irregular heart rate can change the accuracy. These units are also more expensive than the aneroid monitors.

    About finger/wrist blood pressure monitors:

    Tests have shown that finger and/or wrist blood pressure devices are not as accurate in measuring blood pressure as other types of monitors. In addition, they are more expensive than the other monitors. Before you measure your blood pressure:

    * Rest for three to five minutes without talking before taking a measurement.

    * Sit in a comfortable chair, with your back supported and your legs and ankles uncrossed.

    * Sit still and place your arm, raised level with your heart, on a table or hard surface.

    * Wrap the cuff smoothly and snugly around the upper part of your arm. The cuff should be sized to fit smoothly, while still allowing enough room for one fingertip to slip under it.

    * Be sure the bottom edge of the cuff is at least one inch above the crease in your elbow.

    It is also important, when taking blood pressure readings, that you record the date and time of day you are taking the reading, as well as the systolic and diastolic measurements. This will be important information for your physician to have. Ask your physician or another healthcare professional to teach you how to use your blood pressure monitor correctly. Have the monitor routinely checked for accuracy by taking it with you to your physician's office. It is also important to make sure the tubing is not twisted when you store it and keep it away from heat, to prevent cracks and leaks.

    Proper use of your blood pressure monitor will help you and your physician in monitoring your blood pressure.
    Baseline Vital Signs
    • The first set of vital signs measured on a patient.

    Vital Signs and Measurements

    • Breathing: observing chest rise and fall. Count the number of breaths in 30 sec. Multiply by 2 for breaths per min.
    • Pulse: palpate the artery with the index and middle finger tips. Count the number of beats in 30 sec. Multiply by 2 for beats per min.
    • Skin: observing color, feel for temperature and condition using the back of your hand without glove covering, and measure capillary refill by depressing on the patient's nail bed and observe for return of color.
    • Pupils: observe size and reaction to penlight.
    • Blood Pressure: Taken using a sphygmomanometer and a stethoscope.
    • Pulse Oximetry: Measured using a pulse oximeter.

    Normal Vital Signs

    • Breathing
      • 12-20 per min for adults. 20-30 for small children. >30 for infants and newborns.
      • Adequate chest expansion (1 in.).
      • Clear and effortless.
    • Pulse
      • 60-80 per min for adults. Faster for children and the elderly.
      • Strong and regular.
    • Skin
      • Pink (palm and sole), Warm and dry.
      • Fast Capillary refill (under 2 sec male adults and children, 3 for females, and 4 in the elderly).
    • Pupils
      • Normal and equal in size.
      • Respond to light.
    • Blood Pressure: 120 / 80 (systolic / diastolic) in adults. Higher in the elderly and lower in children.
    • Pulse Oximetry: 97-100%

    Detailed Vital Signs and Symptoms

    Breathing

      Detailed Normal Rates of Breathing
      Rate per min 12-20 15-30 20-30 25-40 30-60
      Age group 11+ years 6 - 10 years 6 months - 5 years 30 days - 5 months 0 - 30 days
    • Shallow breathing: inadequate chest or abdominal wall (children) expansion.
    • Labored breathing: use of accessory muscles.
    • Noisy breathing Snoring: tongue obstruction of the upper airway at the pharynx. Wheezing: constriction of the bronchioles. Gurgling: fluid in the upper airway. Crowing or Stridor (harsh high pitched sound): obstruction of the upper airway at the larynx.

    Pulse

      Patient Slow (bradycardia) if below Normal (at rest) Rapid (tachycardia) if above
      Adult 60 60-80 100
      Elderly 90
      Adolescent 50 60-105 105
      Child (5-12 years) 60 60-120 120
      Child (1-5 years) 80 80-150 150
      Infant 120 120-150 150

      Pulse characteristic Possible problems / diagnosis
      Normal rate, regular rate, and strong (full) pulse Normal person at rest
      Rapid, regular and strong Exertion, fright, fever, high blood pressure, initial response to injury and bleeding
      Rapid, regular and weak (also called regular and thready) Indication of shock
      Slow Head injury, drug use (barbiturate or narcotic), poisons, possible cardiac problem
      No pulse Cardiac arrest
      Pulsus paradoxus (decrease in pulse strength during inhalation) Severe cardiac or respiratory injury, illness or blood loss
    • Pulses can be located in the major arteries- Carotid (neck), Femoral (groin), Radial (wrist), Brachial (arm), Popliteal (behind knee), Posterior Tibial (ankle), Dorsalis Pedis (foot).

    Skin

    • Temperature
      • Hot: fever, exposure to heat, localized infection.
      • Warm: normal.
      • Cool: inadequate circulation, shock, or exposure to cold.
      • Cold: extreme exposure to cold.
    • Condition
      • Abnormally Dry: severe dehydration or spinal injury.
      • Dry: normal.
      • Wet or Moist: shock, or heat, cardiac, or diabetic emergencies.
      • Clammy (cool and wet / diaphoretic): indication of shock.
    • Color
      • Pale or mottled: onset of shock.
      • Cyanotic: late sign of shock.
      • Red: anaphylactic or vasogenic shock, poisoning, overdose or other medical condition.
      • Yellow: jaundice, liver problems.
    • Capillary Refill: more reliable for children under 6.
      • Slow cap refill = possible hypoperfusion.

    Pupils

    • Dilated: cardiac arrest, use of stimulant drugs like cocaine, amphetamine, LSD.
    • Constricted: central nervous system disorder, use of narcotics.
    • Unequal: Stroke, head injury, artificial eye, eye drops.
    • Nonreactive: Cardiac arrest, brain injury, drug influence.

    Blood Pressure

      Normal blood pressures
      Patient Systolic (mmHg) Diastolic (mmHg)
      Adult Male 100 + age up to 40 60-85
      Adult female 90 + age up to 40 60-85
      Adolescent 90 and above 2/3 systolic
      Child (1-10 yrs) 80 + (2 x age) +/- 10 2/3 systolic
      Infant (1-12 mo) 70 and above 2/3 systolic
    • Hypertension: high blood pressure in an adult is considered over 140 / 85.
    • Pulse pressure: the difference between systolic and diastolic pressure. Normally falls between 25 % and 50 % of systolic pressure.
    • Narrow (low) pulse pressure: shock, cardiac tamponade (blood filling the pericardial sac, compressing the heart), tension pneumothorax (injury to one lung, causing pressure on the heart and the other lung).
    • Wide (high) pulse pressure: head injury.
    • Measuring blood pressure: Using a sphygmomanometer (wrapped around the arm), applying pressure (by pumping) over the brachial artery until a radial pulse can no longer be detected. Over pump 30 mmHg, then slowly release the pressure. Detect for a return of pulse by either auscultation or palpation.
    • Auscultation: listening with a stethoscope for the return of the brachial pulse. The first sound marks the systolic pressure and the last sound (either a disappearance or a notable drop in volume) marks the diastolic pressure.
    • Palpation: palpating for the radial pulse. When the radial pulse returns, this is the systolic pressure. The palpation technique cannot measure diastolic pressure (a "P" is noted in place of the diastolic pressure). The systolic pressure measured is approximately 7 mmHg lower than those obtained by auscultation.
    • Do not over pump more than what is needed- it can be very painful for the patient.
    • Orthostatic Vital Signs Test (Tilt Test): Measures heart rate and blood pressure for a patient while supine and while standing up. A positive result occurs when the heart rate increases 10-20 bpm and the blood pressure decreases 10-20 mmHg up standing up. This indicates significant blood loss.

    Pulse Oximetry

    • Measured over the tip of the index finger, can detect hypoxia, which can be treated by applying oxygen via a nonrebreather mask.
    • Limitations: Directly measures hemoglobin saturation, not oxygen level. Therefore, false readings can occur during carbon monoxide poisoning. Errors in reading can also occur from nail polish and excessive finger movement.

    Vital Sign Reassessment

    • Stable patients: every 15 min
    • Unstable patients: every 5 min

    The SAMPLE History

    Medical history obtained from the patient, family and bystanders

    • Signs and Symptoms
      • Signs: what you can observe and measure about the patient, such as the vital signs.
      • Symptoms: what the patient describes to you- pain, numbness...etc. You cannot observe these, so you must ask OPQRST
        • Onset: "what were you doing when it started?"
        • Provocation or Palliation: "does anything make it worse? Anything makes it better?"
        • Quality of pain: "can you describe it to me? Is it sharp, dull, constant, intermittent?"
        • Region and Radiation: "where exactly does it hurt? Does the pain extend anywhere else?" (Myocardial infarction produces pain that radiates to the arms and jaw)
        • Severity: "on a scale of 1 to 10, how much does it hurt?"
        • Time: "how long has this been going on? How has this progressed over time?"
    • Allergies: "Do you have any allergies?" This includes medication, food, or other environmental factors. Check for medical alert tags.
    • Medications: "Are you on any medications? Have you taken medications recently?" This includes prescriptions, over-the-counter, birth control pills, illicit drugs (be tactful, indicate that you are not an EMT, not a police officer, and you need the information for treatment purposes), or herbal medicine. Look for medical tags.
    • Pertinent past history: "Have you ever had any illnesses? Operations? Have you ever been admitted to a hospital?" Find out medical problems and past surgical procedures.
    • Last oral intake: "When did you last eat or drink something? What was it?" A diabetic patient who hasn't consumed anything for 8 hours may be hypoglycemic.
    • Events leading up to the injury or illness: "What happened? How did this happen?" The events leading up to the injury provide clues for the underlying cause.

      What's a normal resting heart rate?

      A normal resting heart rate for adults ranges from 60 to 100 beats a minute.

      Generally, a lower heart rate at rest implies more efficient heart function and better cardiovascular fitness. For example, a well-trained athlete might have a normal resting heart rate closer to 40 beats a minute.

      To measure your heart rate, simply check your pulse. Place your index and third fingers on your neck to the side of your windpipe. To check your pulse at your wrist, place two fingers between the bone and the tendon over your radial artery — which is located on the thumb side of your wrist.

      When you feel your pulse, count the number of beats in 15 seconds. Multiply this number by 4 to calculate your beats per minute.

      Keep in mind that many factors can influence heart rate, including:

      •Activity level
      •Fitness level
      •Air temperature
      •Body position (standing up or lying down, for example) •Emotions
      •Body size
      •Medications

      Although there's a wide range of normal, an unusually high or low heart rate may indicate an underlying problem. Consult your doctor if your resting heart rate is consistently above 100 beats a minute (tachycardia) or below 60 beats a minute (bradycardia) — especially if you have other signs or symptoms, such as fainting, dizziness or shortness of breath.

      Your heart rate changes from minute to minute. It depends on whether you are standing up or lying down, moving around or sitting still, stressed or relaxed. Your resting heart rate, though, tends to be stable from day to day. The usual range for resting heart rate is anywhere between 60 and 90 beats per minute. Above 90 is considered high.

      Many factors influence resting heart rate. Genes play a role. Aging tends to speed it up. Regular exercise tends to slow it down. (In his prime, champion cyclist Lance Armstrong had a resting heart rate of just 32 beats per minute.) Stress, medications, and medical conditions also influence the heart rate.

      Here are further guidelines.
      http://www.qureshiuniversity.com/vitalsigns.html

    A–Z alphabetical listing of human health emergency symptoms and signs.
    Medical emergencies.

    Symptoms, signs of medical emergencies.
    Examples of emergency symptoms, signs, and complaints

    What are examples of emergency relevant to an individual?
    Do you know what are emergency medical symptoms, signs, or complaints?
    What are various symptoms, signs, statements, questions, issues, and histories that should raise suspicion of a medical emergency?


    There are at least 161 such symptoms, signs, statements, questions, issues, histories, and scenarios.
    1. Altered level of consciousness

    2. Airway obstruction

    3. Agitated Patient (Acute stress reaction.)

    4. Attempted suicide.

    5. Attempted homicide.

    6. Abuse.

    7. Abdominal Pain.(Stomach pain)

    8. Any sudden or severe pain.

    9. Animal bites (may require rabies or tetanus shot).

    10. Armed Robbery.

    11. Allergic reactions.

    12. Asphyxia

    13. Bradycardia

    14. Bradypnea

    15. Brain death

    16. Breathing difficulties.

    17. Behavior that is dangerous to self or others and cannot be managed.

    18. Bleeding from any orifice or any part of human body that will not stop.

    19. Bleeding which does not stop after applying pressure.

    20. Being beaten by someone.

    21. Burns.

    22. Bites.

    23. Bloody Sputum

    24. Broken bones.

    25. Behavior-related emergencies.

    26. Change in mental status (such as unusual behavior, confusion, and difficulty arousing).

    27. Changes in vision.

    28. Chest pain.

    29. Choking.

    30. Cough with fever.

    31. Coughing up or vomiting blood.

    32. Confusion or changes in mental status

    33. Cuts and abrasions.

    34. Chest or upper abdominal pain or pressure lasting two minutes or more.

    35. Difficulty breathing.

    36. Difficulty Swallowing (Dysphagia)

    37. Difficulty speaking.

    38. Disoriented.

    39. Difficulty getting up.

    40. Difficulty in passing urine.

    41. Difficulty in passing feces.

    42. Domestic Violence

    43. Drowning or near drowning

    44. Dental emergencies.

    45. Emergency diagnosis and treatment in neonatal period.

    46. Emergency diagnosis and treatment after neonatal period.

    47. Earaches and ear infections.

    48. Electrical injury shock.

    49. Emergency Food

    50. Environmental factors (hostile environment).

    51. Fainting.

    52. Fever.

    53. Foreign bodies in nose or ears.

    54. Fainting or loss of consciousness.

    55. Fainting, sudden dizziness, weakness, seizure.

    56. Feeling of committing suicide or murder.

    57. Fever with breathlessness.

    58. Functional impairment (not taking care of self. inability to gain relevant skills and knowledge relevant to age).

    59. Human Rights Violations

    60. Head or spine injury.

    61. Head injury.

    62. Human Pregnancy Emergencies

    63. Hypothermia - frostbite.

    64. Hypotension

    65. Head pain that lasts longer than five minutes.

    66. “High Blood Pressure” is rarely a chief complaint, but instead more commonly a physical finding.

    67. Intentional enforced harms.

    68. Involuntary admission to a psychiatric facility

    69. Irritability

    70. Itching of a Human Being

    71. Loss of consciousness.

    72. Loss of consciousness not related to a seizure

    73. Loosening of social inhibitions.

    74. Loss of memory

    75. Loss of balance or coordination

    76. Likely to be harmful to self or others.

    77. Low abdominal pain.

    78. Medicine overdose.

    79. Medicolegal cases

    80. Nosebleeds.

    81. No pulse

    82. Pain.

    83. Palpitations.

    84. Poisoning.

    85. Poisoning including overdoses of medication.

    86. Persistent or severe vomiting.

    87. Persistent unexplained fever even with Tylenol use.

    88. Puncture wounds.

    89. Personality disorders (harmful to others). Panic attacks.

    90. Psychosis(delusions, hallucinations, catatonia, thought disorder, loss of contact with reality).

    91. Rape.

    92. Pregnancy-related emergencies.

    93. Possible serious bone fractures.

    94. Rashes.

    95. Restlessness

    96. Survival Needs

    97. Starvation

    98. Suicidal feelings.

    99. Surgical Emergencies

    100. Significant trauma (to the head, stomach, chest)

    101. Syncope.

    102. Seizure or convulsion

    103. Seizure lasting over five minutes or continuous seizures

    104. Severe asthmatic attack when prescribed medications do not work

    105. Severe injuries as a result of accidents such as broken bones

    106. Severe reactions to a medication with difficulty breathing or itching.

    107. Severe reactions to insect bites or other previously unknown allergic reactions

    108. Slurred speech

    109. Sunburn.

    110. Severe neck or back injury.

    111. Sexual intercourse due to conspiracy.

    112. Severe or persistent vomiting.

    113. Severe or persistent vomiting or diarrhea.

    114. Severe headache.

    115. Severe burns.

    116. Severe pain in any part of the body that does not subside.

    117. Serious drug reactions with psychiatric or non-psychiatric medications.

    118. Syncope or unconsciousness.

    119. Sudden or severe pain.

    120. Sudden loss of vision.

    121. Suicidal or homicidal feelings.

    122. Sudden asthma attack that does not stop.

    123. Sudden numbness or not being able to move an arm, leg, or one side of the body.

    124. Severe headache with fever or vomiting.

    125. Sudden injury or trauma due to a motor vehicle crash, burns, smoke inhalation, near drowning, wound, etc.

    126. Substance abuse.

    127. Sudden severe pain anywhere in the body.

    128. Sudden dizziness, weakness, or change in vision.

    129. Swallowing a poisonous substance.

    130. Shock symptoms, e.g., confusion, disorientation, cool/clammy, pale skin.

    131. Severe or persistent vomiting or diarrhea.

    132. Stroke or suspected stroke (paralysis, numbness, confusion)

    133. Tachycardia

    134. Tachypnea

    135. Throat Problems

    136. Trauma and Gunshot wounds: What you need to know to save a life.

    137. Trauma Ocular

    138. Trauma with unconsciousness.

    139. Trauma with cuts, sprains, or abrasions.

    140. Trauma with open fracture.

    141. Trauma with pain on mobility.

    142. Trauma with swelling.

    143. Trouble staying awake or alert

    144. Unable to detect breathing

    145. Unconsciousness.

    146. Unconsciousness with diabetes.

    147. Unconsciousness at a public location.

    148. Unusual behavior

    149. Sudden unconsciousness at home.

    150. Unable to move

    151. Uncontrolled bleeding

    152. Upper abdominal pain.

    153. Uncontrolled bleeding.

    154. Unusual abdominal pain.

    155. Unusual or persistent abdominal pain.

    156. Unexplained stupor, drowsiness or disorientation.

    157. Violence

    158. Violence or other rapid changes in behavior.

    159. Vomiting

    160. Vomiting or coughing blood.

    161. Vomiting and diarrhea.

    What will happen if you do not diagnose and treat a medical emergency properly?
    It can lead to death.
    It can lead to disability.
    It can lead to other harms.
    It can lead to medical malpractice.
    It can lead to legal malpractice.

    Altered level of consciousness
    What is an altered level of consciousness?
    Altered level of consciousness (ALOC) means that you are not as awake, alert, or able to understand or react as you are normally.

    What are the levels of impaired/altered human consciousness?
    Syncope Syncope - transient loss of consciousness occurring suddenly and resolving spontaneously
    Confusion Confusion is marked by the absence of clear thinking and may result in poor decision-making.
    Disorientation Disorientation is the inability to understand how you relate to people, places, objects, and time. The first stage of disorientation is when you are disoriented with respect to time (years, months, days). This is followed by disorientation with respect to place, which means you may not know where you are. Loss of short-term memory follows disorientation with respect to place. The most extreme form of disorientation is when you lose the memory of who you are.
    Delirium If you are delirious, your thoughts are confused and illogical. People who are delirious are often disoriented. Their emotional responses range from fear to anger. People who are delirious are often highly agitated.
    Lethargy Lethargy is a state of decreased consciousness that resembles drowsiness. If you are lethargic, you may not respond to stimulants like the sound of an alarm clock or the presence of fire.
    Stupor Stupor is a deeper level of impaired consciousness in which it is very difficult for you to respond to any stimuli, except for pain.
    Coma Coma is the deepest level of impaired consciousness. If you are in a coma, you cannot respond to any stimulus, not even pain.
    Brain death Brain death is the complete and irreversible loss of brain function (including involuntary activity necessary to sustain life).
    A brain-dead individual has no clinical evidence of brain function upon physical examination. This includes no response to pain and no cranial nerve reflexes. Reflexes include pupillary response (fixed pupils), oculocephalic reflex, corneal reflex, no response to the caloric reflex test, and no spontaneous respirations.

    It is important to distinguish between brain death and states that may be difficult to differentiate from brain death (such as barbiturate overdose, alcohol intoxication, sedative overdose, hypothermia, hypoglycemia, coma, and chronic vegetative states).
    Some of the signs of brain death include:
    The pupils don’t respond to light.
    The person shows no reaction to pain.
    The eyes don’t blink when the eye surface is touched (corneal reflex).
    The eyes don’t move when the head is moved (oculocephalic reflex).
    The eyes don’t move when ice water is poured into the ear (oculo-vestibular reflex).
    There is no gagging reflex when the back of the throat is touched.
    The person doesn’t breathe when the ventilator is switched off.
    An electroencephalogram test shows no brain activity at all.
    Brain death is not the same as coma
    Levels of impaired consciousness include: confusion, disorientation, delirium, lethargy, stupor, and coma.

    *Both stupor and coma are often further classified as mild, moderate or deep.

    The Glasgow Coma Scale (GCS) is the most widely accepted method for the evaluation and classification of coma, especially for head-injured patients.

    A GCS score of 8 or less is the generally accepted definition of coma. Those with a GCS of 8 or less are classified as severe, while those with a GCS score of 9 to 12 are categorized as moderate and those with a GCS score of 13 to 15 are mild.

    Coma grades 3 to 5 indicate potentially fatal damage, especially if accompanied by fixed pupils or absent oculovestibular responses. Conversely, scores of 9 and above correlate with good recovery.

    What causes an altered level of consciousness?
    Alcohol
    Dehydration
    Drugs
    Head injury
    Sedatives or other medicines
    Uncontrolled diabetes.
    An altered level of consciousness or coma have almost same causes.
    Coma is an extreme presentation of an altered level of consciousness.

    How should an emergency medical specialist go ahead in diagnosing and treating an altered level of consciousness?

    How do you diagnose and find out the underlying cause or causes of this medical complaint?
    What medical history should you ask relevant to this complaint?

    Syncope
    Signs and symptoms

    History and physical examination are the most specific and sensitive ways of evaluating syncope.
    A detailed account of the event must be obtained from the patient, including the following:
    Precipitant factors
    Activity the patient was involved in before the event
    Position the patient was in when the event occurred
    The following questions should be asked:

    Was loss of consciousness complete?
    Was loss of consciousness with rapid onset and short duration?
    Was recovery spontaneous, complete, and without sequelae?
    Was postural tone lost?


    Causes of altered level of consciousness

    · Structural: brain lesions that destroy tissue or occupy space that is normally occupied by the brain

    · Epilepsy
    · Tumors
    · Trauma

    · Cardiovascular: temporary or permanent interruption to the blood supply to the brain

    · Vasovagal response
    · CVA
    · TIA
    · Hypertensive encephalopathy
    · Shock
    · Dysrhythmias

    · Metabolic: abnormally high or low levels of circulating metabolites

    · Hypoxia
    · Hypoglycemia
    · Hyperglycemia
    · Renal failure (uremia)
    · Liver failure
    · Infection (sepsis)

    · Environmental: external factors that cause deterioration of central nervous system function

    · Overdose
    · Toxins

    · Behavioral: abnormal mental status that results from internal factors

    · Psychiatric disorders

    Mnemonic for Causes of Altered Level of Consciousness

    A - alcohol, acidosis, anoxia
    E - epilepsy, environment
    I - insulin (diabetes)
    O - overdose
    U - uremia (metabolic), underdose
    T - trauma, toxins, tumors
    I - infection (sepsis)
    P - psychiatric disorders
    S - stroke (CVA)
    Symptoms that may be associated with decreased consciousness are:

    •seizures
    •loss of bowel or bladder function
    •poor balance
    •falling
    •difficulty walking
    •fainting
    •lightheadedness
    •irregular heart beat
    •rapid pulse
    •low blood pressure
    •sweating
    •fever
    •weakness in the face, arms, or legs

    Common Underlying Causes of Decreased Consciousness

    Drugs, alcohol, substance abuse, drug overdose, certain medications, epilepsy, low blood sugar, stroke, and lack of oxygen to the brain are common causes of decreased consciousness. Other underlying causes of decreased consciousness include:
    •cerebral hemorrhage
    •dementia (Alzheimer’s)
    •head trauma
    •heart disease
    •heat stroke
    •liver disease
    •uremia (end stage kidney failure) •shock

    Sleep

    Sleep is a normal state of physical and mental inactivity from which the individual may be aroused to normal consciousness. A sleeping individual gives very little evidence of being aware of self or environment. Yet, he/she differs from the comatose patient in that he/she may still respond to unaccustomed stimuli and at times is capable of some form of mental activity in the form of dreams which leave their traces in memory.

    Altered Level Of Consciousness (Child)

    Level of consciousness is a measure of a person’s ability to interact with other people and to react to the surroundings. A child with an altered level of consciousness may be irritable for a number of hours. The child cannot be calmed by holding, rocking, or feeding. Some children may be hyperactive and can’t sleep. Others may be very sleepy and difficult to wake. Affected children may appear limp, with poor muscle tone. They may not respond to touch or voices. Their look may be vacant or blank. They may not make eye contact. Their cry may be weak and feeble. Some children may not move for a long time or show little interest in moving. They may be confused.

    There are many causes of altered consciousness. Generally, they are divided into medical reasons or injuries. The child may have low blood sugar, an infection, a metabolic abnormality, or a systemic disease. Other causes include drugs, abuse, or injuries such as a fall.

    A decreased level of consciousness is a medical emergency. Doctors must quickly determine the cause. This may include laboratory, radiology, and other types of testing. Initial treatment stabilizes breathing and heart rate. An intravenous (IV) line is used to give medications. Once the cause is determined, specific treatment for that cause is given. In almost all cases, the child will be admitted to the hospital for observation.

    History

    Perform a focused history and physical exam with particular attention to:
    A. When was the patient last completely well?
    B. Determine the onset, progression and duration of symptoms.
    C. What signs and symptoms were present before the change in level of consciousness (e.g., headaches, seizures, confusion, trouble breathing, fever/chills?)
    D. Obtain a past medical history, including alcohol abuse, diabetes, epilepsy, hypertension. E. What medications has the patient been, or is the patient supposed to be, taking (including over the counter medications)?
    F. Is there a history of head trauma?
    G. Has the patient noted any chest pain, dyspnea or irregular heartbeat?
    H. Has the patient been incontinent?

    Physical Examination

    A. Perform an initial assessment.
    B. Perform a focused history and physical exam with particular attention to:
    1. Skin
    (a) Is the patient sweaty?
    (b) Is the skin hot or cold?
    (c) What is the skin color?
    2. Assess patient from head to toe for injuries:
    (a) Is there any bruising?
    (b) Is there any evidence of head or neck trauma?
    C. Assess the level of consciousness.

    D. Assess the patient's neurological condition.
    1. Check pupils for size, symmetry, reactivity.
    2. Assess motor function. Is the patient moving all four extremities? Is there equal grip strength? Is there posturing?
    3. Is sensation to touch intact in all four extremities?
    4. What is the last thing the patient can recall?
    E. Are there signs of trauma which might have caused altered mental status/coma (e.g., head trauma, hematomas, Raccoon eyes, Battle's sign)?
    F. Are there other injuries, e.g., hip or wrist injury from a fall?
    G. Is there an unusual breath odor, e.g., alcohol, fruity/acetone)?
    H. Is there evidence of chemical use, e.g., needle tracks, runny nose?
    I. Inspect the surroundings
    1. Check for pill bottles, syringes, etc. (bring them with the patient).
    2. Note any odor in the house, unvented heaters, etc. (carbon monoxide is odorless).
    J. At the discretion of local medical direction, a specific prehospital stroke assessment may be made.

    The General Physical Exam Vital Signs

    The vital sign determinations may contribute important clues to the underlying process responsible for the altered level of consciousness. The temperature should be taken rectally. Fever suggests the presence of a sever systemic infection such as pneumonia, bacterial meningitis, or a brain lesion that has disturbed the temperature-regulating centers. An excessively high body temperature, ____ to _____, associated with dry skin should raise suspicion of heat stroke. Hypothermia is frequently observed in alcoholic or barbituate intoxication, extracellular fluid deficit, or in shock and peripheral circulatory failure. Slow respirations suggests barbituate, morphine, or other narcotic intoxication, whereas rapid deep breathing (Kussmaul respirations) suggests diabetic or uremic acidosis but may also occur in intracranial disease. Rapid breathing accompanied by an expiratory grunt and associated with fever is a common finding in lobar pneumonia. Diseases that elevate the intracranial pressure or cause damage to the brain, especially the brain stem, often cause slow, irregular or periodic (Cheynes-Stokes) breathing. Exhalation through pursed lips is suggestive of hypokalemia. Apneustic breathing is characterized by a pause of 2-3 seconds between inspiration and expiration and is attributed to a lesion in the pontine respiratory center. Ataxic respirations are manifested by an irregular pattern of inspiratory and expiratory respirations seen in association with lesions in the medullary respiratory center. If the pulse is exceptionally slow, it suggests a heart block and the possibility of Stokes-Adams syndrome, or if combined with hypertension and periodic breathing, increased intracranial pressure. A tachycardia of 150 or above suggests an arrhythmia with possible insufficiency of cerebral circulation. The presence of atrial fibrillation suggests the possibility of a cerebral embolism. Blood pressure observations are important. Marked hypertension occurs with cerebral hemorrhage and hypertensive encephalopathy and at times with increased intracranial pressure. Hypotension is seen in diabetic coma, alcohol or sedative drug intoxication or in loss of blood due to internal hemorrhage.

    The Ocular Fundi

    Careful observation of the optic fundi without the use of mydriatics that interfere with pupillary reflexes may produce information about hypertension, systemic arteriosclerosis, diabetes mellitus, hemorrhages, and the presence or absence of papilledema. If a lesion is suspected that is producing elevated intracranial pressure, examination of the ocular fundi for the presence or absence of papilledema should be considered an emergency procedure. Examination of the Skin Inspection of the skin may also yield valuable clinical information. Multiple bruises, especially in the scalp area, suggest cranial trauma. Bleeding from the nose, an ear or orbital hemorrhage also raises the possibility of trauma. Marked pallor suggests internal hemorrhage. Rashes are seen in a number of infectious diseases including meningococcemia, endocarditis, typhus, or Rocky Mountain fever. The dementia of pellagra is usually accompanied by typical skin lesions on the face and hands and diarrhea. The physician should examine the skin closely for evidence of needle marks suggestive of substance abuse or insulin usage.

    Odor of the Breath

    Often neglected, the odor of the breath may afford a valuable diagnostic clue. The odor of alcohol is easily recognizable, but may be a misleading clue that detracts from a more significant diagnosis. The “fruity” odor of diabetic acidosis, the uriniferous odor of uremia, and the musty, “mousy” odor of hepatic coma are sufficiently distinctive to provide valuable diagnostic clues. While checking breath odor, the physician has the opportunity to inspect the mouth for evidence of tongue-biting and gum hypertrophy, tell-tale evidence of epilepsy and anti-convulsant drug use.

    Cardiorespiratory and Abdominal Examinations

    The heart should be examined for the apical pulse rate and rhythm, the presence of murmurs and cardiac enlargement, as well as for evidence of congestive heart failure and carotid artery bruits and hemodynamics. The extremities should be examined for peripheral pulses, evidence of sclerosis, cyanosis, edema and clubbing of the fingers. The character of breathing should be noted and the lungs examined for evidence of percussive and auscultatory evidence of infiltration, consolidation, fluid or congestion. The abdominal examination should include evidence of hepatomegaly and the presence of masses. A rectal examination should include evaluation of the prostate and examination of the stool for occult or gross blood.

    The Neurological Examination Observation of the Patient

    Careful observation of the obtunded, stuporous or comatose patient may yield considerable information concerning the function or lack of function of various parts of the nervous system. One of the most helpful procedures is to sit at the patient’s bedside for five to ten minutes and observe what he/she does. The predominant postures of the body, the position of the head and eyes, the rate, depth and rhythm of respiration, and the pulse should be noted. The state of responsiveness should then be estimated by noting the patient’s reaction to verbal commands, his/her capacity to execute a simple response and the response to painful stimuli. The obtunded patient is usually capable of accurately localizing a painful stimulus and will fight forcefully against it accompanied by grimacing and vocalization. As unconsciousness progresses toward coma, these reactions may be replaced by stereotyped responses having specific anatomic or pathologic connotations. These “posturing” responses include the following: Decorticate posture or rigidity includes flexion of the arms and wrists with the legs extended with internal rotation and plantar flexion. This posture suggests severe bilateral damage in the hemispheres above the midbrain with involvement of the corticospinal tracts. Decerebrate posture or rigidity includes pronation and extension of the arms and extension of the legs with plantar flexion occasionally accompanied by opisthotonos and trismus. This posture suggests damage to the corticospinal tracts arising in the midbrain or caudal diencephalon. Abnormal posturing or motor activity is also seen under other circumstances. External rotation of a leg or lack of restless movements on one side suggest a hemiparesis. Multifocal myoclonus, characterized by sudden, generalized muscle contractions, are commonly seen in metabolic disorders especially uremia, anoxia or drug ingestion. Asterixis (palmar flipping) is commonly seen in metabolic encephalopathies associated with drowsiness and confusion. It is most commonly seen in hepatic encephalopathy and has been attributed to accompanying ammonia intoxication.

    Pupillary and Brainstem Reflexes

    Pupillary reflexes depend on the correct functioning of centers situated in the brainstem (diencephalon, pons and midbrain) and provide valuable information on the localization of lesions in the brainstem. Symmetrically reactive round pupils, 2.5 to 5 mm in diameter, usually exclude midbrain damage as a cause of coma. One enlarged (greater than 5 mm in diameter) unreactive or poorly reactive pupil usually results from either an intrinsic midbrain lesion on the same side or, far more commonly, is secondary to stretching or compression of the third nerve (oculomotor) by the secondary effects of a mass. Oval and slightly eccentric pupils accompany early midbrain-third nerve compression. Bilaterally dilated and unreactive pupils indicate severe midbrain damage usually by compression from transtentorial herniation or from anticholinergic drugs. Small, but not pinpoint, pupils (1 to 2.4 mm in diameter) that react are most commonly seen in metabolic encephalopathies. Bilateral pinpoint pupils that still react (but may require a magnifying glass to verify) are characteristic of narcotic or barbiturate overdose but may also occur as the result of a pontine hemorrhage. Skew deviation of the eyes (one up or down) is an indication of a brainstem lesion. Forced downward deviation of the eyes such as looking at one’s nose has been described in cases of thalamic hemorrhage and is usually accompanied by pinpoint nonreactive pupils.

    Eye Movements

    Eye movements are an additional valuable component of the neurological examination, contributing information concerning the location of the etiological mechanism causing an altered level of consciousness. The eyes are first observed by elevating the lids and noting the resting position and spontaneous movements of the globes. Unconscious patients, in whom the centers that mediate eye movements are intact, commonly have a slightly divergent straightforward gaze and slow, horizontal conjugate eye movements (roving eye movements). In these patients, turning the head briskly from side to side elicits conjugate eye movements directed opposite to the head rotation. This is the oculocephalic or doll’s head reflex which is absent in the normal alert individual. Cyclic vertical downward movements are seen in specific circumstances. “Ocular bobbing” describes a brisk downward and slow upward movement of the globes associated with loss of horizontal eye movements and is diagnostic of bilateral pontine damage. “Ocular dipping” is a slower arrhythmic downward movement followed by a faster upward movement in patients with normal reflex horizontal gaze and denotes diffuse anoxic damage of the cerebral cortex. The oculovestibular response is elicited by caloric stimulation of the semicircular canals by irrigating the external ear canal with cold water. This produces tonic bilateral eye deviation toward the stimulated side. In a normal awake individual, this type of stimulation causes nystagmus away from the stimulated side. Full horizontal excursion of the eyes to both sides is possible only when the nuclei and the internuclear connections between the third and sixth nerves are intact. A normal oculovestibular response indicates that the cause of unconsciousness is not a structural brainstem lesion. Unilateral lesions in the pontine gaze center adjacent to the sixth nerve nucleus result in a paralysis of ipsilateral gaze and contralateral deviation of the eyes and a failure of caloric stimulation to move the eyes beyond the midline. Conjugate horizontal ocular deviation at rest or incomplete conjugate eye movements with head turning indicate damage in the pons on the side of the gaze paresis or frontal lobe damage on the opposite side. This phenomenon may be summarized by the following aphorism: The eyes look toward a hemispheral lesion and away from a brainstem lesion. The pathway that connects the pontine gaze center to the midbrain oculomotor nuclei is called the medial longitudinal fasciculus (MLF). When its fibers are damaged, the ipsilateral medial rectus muscle fails to contract when required for voluntary or reflex conjugate horizontal gaze. This is called internuclear ophthalmoplegia and can be demonstrated in the unconscious patient by either oculocephalic or oculovestibular testing.

    Testing Office and Laboratory

    Blood chemistry tests are made routinely to investigate metabolic, toxic or drug-induced encephalopathies. The major areas of metabolic abnormalities encountered in clinical practice are those of electrolytes (sodium, potassium, chloride), calcium, blood urea nitrogen (BUN), serunm creatinine (Cr), glucose and hepatic dysfunction (ammonia). Toxicological analyses are of great value in any case of ALC where the diagnosis is not immediately apparent. However, the presence of exogenous drugs or toxins, especially alcohol, does not ensure that other factors, particularly head trauma, may not also contribute to the clinical state. The legal blood level above which alcohol is incriminated as a possible etiologic factor is 100 mg/dl in most states. Ethanol levels of 200 mg/dl in individuals who are non-habituated to alcohol generally cause confusion, and levels above 300 mg/dl are associated with stupor. The development of tolerance may allow the chronic alcoholic to maintain wakefulness above these levels.

    Radiologic Studies

    Skull roentgenograms, especially in cases of craniofacial trauma, are essential in detecting fractures, shifts of the pineal body from the midline, and abnormal calcifications. In the case of trauma and the possibility of vertebral damage, roentgenograms of the cervical and thoracic spine must be taken. Computerized tomography (CT) scanning and magnetic resonance imaging (MRI) yield information about structural damage in the supratentorial area and are well-suited for visualizing and diagnosing hemorrhages, tumors, hydrocephalus and brain edema and/or softening due to cerebral thrombosis or emboli. Patients for CT or MRI studies should be carefully selected because most cases of ALC are metabolic or toxic in origin. The notion that a normal CT scan excludes an anatomic lesion, however, is erroneous. Early bilateral hemisphere infarction, small brainstem lesions, encephalitis, meningitis, decreased or absent cerebral perfusion, superior saggital sinus thrombosis and even subdural hematomas that are isodense to adjacent brain may be overlooked. Even MRI may fail to demonstrate these processes early in their evolution. Nevertheless, in coma of unknown etiology, a CT or MRI scan should be obtained. In mass lesions, shifting of the pineal body correlates roughly with the level of consciousness. Three to 5 mm of horizontal displacement of the pineal body from the midline correlates with obtundation; 5 to 8 mm correlates with stupor; and greater than 8 mm displacement correlates with coma.

    The Electroencephalogram (EEG)

    The EEG tests neuronal physiology and therefore is important in the diagnosis and follow-up of metabolic or drug-induced encephalopathies. It is seldom diagnostic in cases of coma except to identify clinically unrecognized seizures. Specific EEG patterns have been described in metabolic coma due to hepatic failure and other mechanisms. A pattern described as “alpha coma” has been associated with either high pontine or diffuse cortical damage and is indicative of a poor prognosis.

    Cerebrospinal Fluid (CSF) Examination

    CSF examination is important when the differential diagnosis includes the possibility of meningitis, encephalitis or subarachnoid hemorrhage in which the CT is normal. In general, the CT has replaced the lumbar puncture as a diagnostic test in intracerebral hemorrhage. Spinal fluid pressure, cell count and differential, levels of protein and sugar, culture and viral studies are useful diagnostic contributions made by examination of the CSF. Differential Diagnosis In many instances, an altered state of consciousness spanning the spectrum of confusion through coma is part of an obvious medical problem such as known drug ingestion, hypoxia, stroke, trauma, or liver or kidney failure. Attention is then appropriately focused on the primary underlying illness. Some general rules are helpful in establishing the diagnosis if the underlying cause is unknown. Coma that appears subacutely or slowly is usually related to preceding medical or neurologic problems, including the secondary edema that surrounds a pre-existing lesion. Illnesses that cause sudden or acute coma are due to drug ingestion or to one of the catastrophic brain lesions such as hemorrhage, trauma, hypoxia or rarely, acute basilar artery thrombosis.

    The demonstration of focal brain disease or meningeal irritation with CSF abnormality and abnormalities in the CT, MRI or EEG, helps in the differential diagnosis of ALC. For purposes of differential diagnosis, the diseases that frequently result in ALC can be conveniently divided into three classes as shown in Table 3.

    Table 3 – The Differential Diagnosis of Altered States of Consciousness A. Disease that cause no focal or lateralizing neurologic signs or alterations of the cellular content of the CSF.

    1. Intoxications (alcohol, barbiturates, narcotics)
    2. Metabolic disturbances (diabetic acidosis, uremia, hepatic coma, hypoxia, hypoglycemia, Addisonian crisis
    3. Severe systemic infections with our without septicemia
    4. Circulatory shock from any cause
    5. Hypertensive encepalopathy
    6. Hypothermia or hyperthermia
    7. Status epilepticus

    B. Diseases that cause meningeal irritation with either blood or an excess of white blood cells in the CSF, usually without focal or lateralizing signs.

    1. Subarachnoid hemorrhage from ruptured aneurysm, occasionally trauma
    2. Acute bacterial meningitis
    3. Encephalitis

    C. Diseases that cause focal or lateralizing signs with our without changes in the CSF. (These may be subdivided into supratentorial and infratentorial lesions). CT and/or MRI are usually positive.

    1. Brain hemorrhage
    2. Cerebral thrombosis or embolism with secondary brain edema and/or softening
    3. Brain abscess
    4. Epidural and subdural hematoma with brain contusion and/or compression.
    5. Brain tumor
    6. Cerebral thrombosis

    Metabolic encephalopathies are diffuse disturbances of neuronal function that occur when the substrates required for neuronal metabolism are in short supply, when the internal environment of the cell is disturbed by external agents such as drugs or environmental poisons, or as a complication of the failure of another organ system such as the kidneys, liver or the endocrine, cardiovascular or respiratory systems.

    When the metabolic impairment is mild, the onset of symptoms can be insidious and nonspecific. Subtle changes in mentation such as mild drowsiness, dullness of affect, and decreased motor coordination precede the more ominous alteration in the level of consciousness such as confusion, delirium, stupor and eventually coma.

    Treatment

    Acute Care / Hospitalization

    It is apparent that in almost all instances, hospitalization will be required in all serious alterations in the level of consciousness. Until that can be safely accomplished, however, the role of the primary care physician, when confronted by a patient with an altered level of consciousness as a first priority is the institution of emergency treatment necessary to preserve and maintain vital signs and to stabilize the patient to prevent further damage to the nervous system and death. This includes the ABCs of basic life support – airway, breathing and circulation.

    An oropharyngeal airway is adequate to keep the pharynx open in patients who are breathing normally. Endotracheal intubation is indicated if there is apnea, upper airway obstruction or emesis, or if the patient is liable to aspirate. Mechanical ventilation will be required if there is hypoventilation. Intravenous access should be established as soon as possible and blood drawn for blood counts, blood chemistry determinations, toxic screen and blood gasses. Definitive Therapy

    Dextrose (50% if hypoglycemia is suspected) with added thiamine and naloxone should be administered if hypoglycemia and/or substance abuse are even remote possibilities. Thiamine is helpful in preventing Wernicke’s encephalopathy in malnourished alcoholic individuals. Ultimately, nasogastric intubation and bladder catheterization will probably be necessary. Overdistension of the bladder should be prevented.

    Only after initiation of urgent, potentially life-saving measures should a limited physical examination be done primarily to serve as a guide for the care of the patient in his/her transportation to the hospital. Evidence of head trauma should be sought and trauma to the neck and spine should be carefully considered at the time of first contact with the patient. The skull should be palpated for hematomas and the mastoid and periorbital tissues examined for ecchymoses. If neck trauma can be safely excluded, the patient should be placed in a semiprone position so that secretions and vomitus do not enter the endotracheal tree.

    The patient should be monitored closely during transportation to the hospital and most ambulances and emergency medical care vehicles are equipped to initiate emergency diagnostic and therapeutic measures. Therapeutic measures that can be instituted enroute to the hospital include treatment of shock and the administration of 100% oxygen by mask. Hypothermia can be helped with blankets and warming devices and hyperthermia by the use of alcohol sponging and the application of cooling solutions. If the patient is conscious, control of anxiety, restlessness and panic may be a problem since all but mild sedation should be avoided.

    The hospital should be alerted to the arrival of the patient so that appropriate neurological/neurosurgical consultation will be available for decisions concerning further diagnostic and therapeutic procedures.

    Complications

    The physician should be alert for the development of complications that may arise during a period of altered consciousness. Confused patients are prone to fall either in walking or getting out of bed. Many of the patients, especially postmenopausal women, will have accompanying osteoporosis and are at increased risk for serious vertebral and hip fractures. Households, hospital and convalescent, nursing and retirement facilities should provide and participate in providing instructions against falling as well as providing safety devices (handrails, etc.) for the prevention of falls. The consequences of hip fractures in this group of patients include long periods of disability and even death.

    Precautions should be taken to prevent the bedridden patient with prolonged coma from the development of decubitus ulcers as well as nococomial infections such as pneumonia and bladder infections secondary to an indwelling catheter.

    Many of the survivors of an altered state of consciousness will achieve complete or significant recovery of function even in the case of severe head trauma. However, as many as 30 to 40% will remain in prolonged states of severely reduced consciousness subsequent to achieving medical stability.23 The nature of the residual damage depends on the nature and location of the underlying causative agent and the severity of the process.

    Relatively few patients will remain in coma, that is, with eyes closed and no evidence of wakefulness for more than four weeks. Patients who show no signs of consciousness after their eyes open usually fit the criteria for the vegetative state (VS). Persistent vegetative state (PVS) is a prognostic term referring to a chronic condition in which basic arousal (i.e., wakefulness) and life-sustaining functions (e.g., respiration, blood pressure) are generally intact despite the absence of behavioral signs of meaningful interaction with the environment. The American Academy of Neurology (AAN) had recently adopted the position that the VS should be termed “persistent” at one month and considered “permanent” after three months following nontraumatic causes of unconsciousness and after twelve months following traumatic injury. However, exceptions to this have been cited.

    The locked-in syndrome (LIS) is another residual of the state of altered consciousness. It refers to a specific neurobehavioral diagnosis seen in patients who are alert, cognitively aware of their environment and capable of communication, but cannot move or speak. There are various subclassifications of LIS that relate to the extent of motor and verbal impairment ranging from complete to partial.

    Minimally responsive (Min-R) is a descriptive term that refers to patients who are no longer comatose or vegetative, but remain severely disabled. The term should be reserved for use with those patients whose responses are inconsistent but indicative of meaningful interaction with the environment. These patients will respond to a specific command or an environmental prompt (e.g., an attempt to shake an outstretched hand).

    Akinetic mutism (AM) is a neurobehavioral condition that is characterized by severely diminished neurologic drive or intention. Although movement and speech are markedly deficient, spontaneously visual tracking is always intact. AM is usually considered a subgroup of the minimally responsive state because meaningful responses are typically inconsistent but can usually be elicited after sensory or pharmacological stimulation.

    Most common are residual palsies and paralyses that are usually the residuals of brain damage or a focal lesion such as a brain tumor, hemorrhage, or a cerebrovascular thrombosis or embolism. These are often accompanied by defects in cognition and speech. Seizures may also occur secondary to a focal lesion. Headache, vertigo, light-headedness and hearing loss are also recognized as sequelae to lesions producing ALC, especially head trauma. Most of these bothersome but relatively mild conditions are amenable to palliative or remedial therapies such as physical medicine and rehabilitation, auditory and visual aids, behavioral therapy and biofeedback, and pharmacological agents such as anticonvulsants and antivertigo agents.

    Special Circumstances

    Vehicular accidents and substance abuse have resulted in an increase in incidence of altered levels of consciousness, especially in adolescents and young adults. The ready availability of motor vehicles in today’s society plus less stringent speed limitations has resulted in an increase in vehicular accidents and head trauma in the younger age groups. In many instances, this has been accompanied by the other burgeoning health problem of substance abuse. An adolescent or young adult seen in an altered level of consciousness in the absence of head trauma or other obvious cause id a definite candidate for drug overdosage and should be handled as such. Tell-tale needle tracks should be sought and nasogastric aspiration should be done to remove any residuals of an ingested agent. After withdrawal of a blood sample for appropriate analyses, the routine administration of naloxone is recommended in these cases. Airway patency should be established and treatment for shock initiated if present.

    When to Refer

    All ALC patients referred to a hospital should have the benefit of neurological and/or neurosurgical consultation. All such cases will certainly require further diagnostic and therapeutic procedures done by specialized personnel and facilities.

    In the patient presenting with delirium or catatonic stupor, psychiatric consultation should be obtained if a functional psychosis is suspected. When mild confusion is seen in an office or outpatient setting and the patient is in no danger of harming himself or others, the primary care physician can resort to appropriate outpatient consultation for diagnostic testing and therapeutic recommendations. The rapid rise in the frequency of occurrence of Alzheimer’s disease poses a problem of this type especially for the elderly.

    Prognosis The Glasgow Coma Scale (see Table 3) has predictive value especially in the case of head injury and traumatic brain injury (TBI). Major points include a 95% death rate in patients whose pupillary reactions or reflex eye movements are absent six hours after the onset of coma and there is a 91% death rate if the pupils are unreactive after 24 hours.

    Prognostication of nontraumatic alterations in consciousness is difficult because of the heterogeneity of the contributing disease. Metabolic coma has a generally more favorable prognosis than anoxic or traumatic coma. Statistics of this type from general municipal hospitals tend to be skewed by the preponderance (as high as 60%) of cases due to alcohol. Unfavorable signs in the first hours after admission of a comatose patient include the absence of any two of pupillary reactions, corneal reflex (blinking response to gentle stimulation of the cornea), or the oculovestibular response. The addition of absence of eye opening and muscle tone predict death, progressive disability or the vegetative state.

    The prognosis for regaining full mental faculties once the vegetative state is reached is almost nil and physicians are becoming less reluctant to withdraw life-support measures as prediction becomes more accurate.

    Diagnosis and treatment of decreased consciousness begins with a complete medical history and physical examination, which includes a detailed neurological evaluation. Medical personnel will want to know about any medical problems you have (such as diabetes, epilepsy, or depression), and any medications you are taking (such as insulin or anticonvulsants). They will also ask if you have a history of abusing illegal or prescription drugs or alcohol.

    In addition to your complete history and physical, the doctor may order the following tests: •CBC (complete blood count): a low hemoglobin level indicates anemia and an elevated white blood cell count indicates infections, such as meningitis or pneumonia

    •toxicology screen to detect the presence and levels of medications, illegal drugs and poisons in your system

    •electrolyte panel to measure levels of sodium, potassium, chloride, and bicarbonate

    •liver function tests to measure the health of your liver

    •EEG (electroencephalogram): a noninvasive test that uses scalp electrodes to evaluate brain activity

    •EKG (electrocardiogram): a non-invasive test that evaluates heart rate, rhythm, and health

    •chest X-ray to evaluates the heart and lungs

    •CAT scan of the head: a noninvasive test that uses X-rays to make high-resolution images of the brain

    •MRI of the head: a noninvasive test that uses nuclear magnetic resonance to make high-resolution images of the brain.

    Treatment

    Treatment for decreased consciousness depends upon its underlying cause. Your outlook worsens the longer you spend less than fully consciousness.
    {If acute arrhythmia/dysrhythmia, follow appropriate arrhythmia/dysrhythmia protocols.}
    {If shock is present, follow hypotension protocol.}
    {If trauma noted, follow appropriate protocol where indicated.}
    {If the patient has diabetes, follow diabetic emergencies protocol.}

    A. Establish an airway, maintain as indicated, suction as needed; assist ventilations as indicated. B. Administer high concentration oxygen.
    C. Transport the patient in the coma/recovery position (if trauma is suspected, transport supine with cervical collar and backboard).

    Intermediate

    D. If the patient is in respiratory arrest, perform advanced airway management.
    E. Secure IV access. Obtain blood specimen for glucose determination at the hospital if the receiving hospital desires it.
    F. Perform capillary blood glucose determination.
    G. If patient’s blood glucose level is <80 mg/dl, administer dextrose 50% 25 gm
    IV in a secure vein for an adult (standing order for paramedics) or 0.5 - 1 gm/kg for a child.
    H. Unless patient responded to dextrose administration, contact medical direction for an order to administer 2 mg of naloxone intravenously or intranasally to an adult (standing order for paramedics), 0.01 mg/kg for a child.
    I. ? Administer thiamine 100 mg IV if dextrose is to be administered.
    J. ? If IV access cannot be secured and the patient's blood glucose level is <80 mg/dl, administer 1 mg glucagon IM.

    Brain death

    What does it mean to be brain dead?
    Some of the signs of brain death include:
    The pupils don’t respond to light.
    The person shows no reaction to pain.
    The eyes don’t blink when the eye surface is touched (corneal reflex).
    The eyes don’t move when the head is moved (oculocephalic reflex).
    The eyes don’t move when ice water is poured into the ear (oculo-vestibular reflex).
    There is no gagging reflex when the back of the throat is touched.
    The person doesn’t breathe when the ventilator is switched off.
    An electroencephalogram test shows no brain activity at all.
    Brain death is not the same as coma

    What causes brain death?
    What causes brain death?
    What happens after a brain death diagnosis is made?
    Here are further guidelines.

    Airway obstruction
    Upper airway obstruction
    What is an airway obstruction?
    What causes an airway obstruction?
    What are the symptoms of partial and complete airway obstruction?
    When does a physician need to place an endotracheal tube for a person?
    What is endotracheal intubation?
    What kind of tube is used?
    How do they put the tube down into the trachea?
    What is the purpose of endotracheal intubation?
    What are the complications of endotracheal intubation?
    What should you know about managing airway obstruction?
    The airway can become narrowed or blocked due to various causes.

    Questions you need to answer.

    What is an airway obstruction?
    An airway obstruction is a blockage in the airway. It may partially or totally prevent air from getting into your lungs. Some airway obstructions are life-threatening emergencies. They require immediate medical attention to prevent death.

    What causes an airway obstruction?
    Anaphylaxis
    Chemical Burns
    Diphtheria
    Epiglottitis
    Fire or burns from breathing in smoke
    Infections of the upper airway area
    Injury to the upper airway area
    Laryngitis
    Peritonsillar Abscess
    Retropharyngeal Abscess
    Swallowed (or Inhaled) Foreign Object
    Tumor
    Tracheomalacia (weakness of the cartilage that supports the trachea) Vocal cord problems

    What are the symptoms of partial and complete airway obstruction?
    Symptoms of Partial Airway Obstruction
    Snoring
    Retraction of the sternum
    Rocking motion of the chest not in sync with respiratory effort
    Harsh, high-pitched sound upon inspiration (stridor)
    Hypoxemia
    Hypercarbia

    Symptoms of Complete Airway Obstruction

    Lack of any air movement perceived by feeling with the hand over the mouth or placing the ear over the mouth
    Lack of breath sounds while listening with stethoscope to lung fields
    Retraction of the sternum and rib cage
    Rocking motion of the chest not in sync with respiratory effort
    Hypoxemia
    Hypercarbia

    Symptoms vary depending on the cause. But some symptoms are common to all types of airway blockage.

    They include:
    •Agitation or fidgeting
    •Bluish color to the skin (cyanosis)
    •Changes in consciousness
    •Choking
    •Confusion
    •Difficulty breathing
    •Gasping for air
    •Panic
    •Unconsciousness
    •Wheezing, crowing, whistling, or other unusual breathing noises indicating breathing difficulty

    When does a physician need to place an endotracheal tube for a person?
    Endotracheal intubation is indicated in several clinical situations including acute hypoxemic or hypercapnic respiratory failure, or impending respiratory failure. This procedure is also used to protect the airway in conditions of upper airway obstruction, either mechanical or from airway pathology. Patients at risk for aspiration, most commonly from central nervous system derangements may benefit from elective intubation. In addition, elective EI is performed for many operative procedures; at times to facilitate certain diagnostic procedures (ex. COMPUTED tomographic scan); and to aid in respiratory hygiene. Another potential indication for EI includes the need to hyperventilate by mechanical ventilation, attempting to reduce intracranial pressure in patients with acute intracranial hypertension.6

    What is endotracheal intubation?
    Endotracheal intubation is a procedure by which a tube is inserted through the mouth down into the trachea (the large airway from the mouth to the lungs). Before surgery, this is often done under deep sedation. In emergency situations, the patient is often unconscious at the time of this procedure.

    What kind of tube is used?
    The tube that is used today is usually a flexible plastic tube. It is called an endotracheal tube because it is slipped within the trachea.

    How do they put the tube down into the trachea?
    The doctor often inserts the tube with the help of a laryngoscope, an instrument that permits the doctor to see the upper portion of the trachea, just below the vocal cords. During the procedure the laryngoscope is used to hold the tongue aside while inserting the tube into the trachea. It is important that the head be positioned in the appropriate manner to allow for proper visualization. Pressure is often applied to the thyroid cartilage (Adam's apple) to help with visualization and prevent possible aspiration of stomach contents.

    What is the purpose of endotracheal intubation?
    The endotracheal tube serves as an open passage through the upper airway. The purpose of endotracheal intubation is to permit air to pass freely to and from the lungs in order to ventilate the lungs. Endotracheal tubes can be connected to ventilator machines to provide artificial respiration. This can help when a patient is unconscious and by maintaining a patent airway, especially during surgery. It is often used when patients are critically ill and cannot maintain adequate respiratory function to meet their needs. The endotracheal tube facilitates the use of a mechanical ventilator in these critical situations.

    What are the complications of endotracheal intubation?
    If the tube is inadvertently placed in the esophagus (right behind the trachea), adequate respirations will not occur. Brain damage, cardiac arrest, and death can occur. Aspiration of stomach contents can result in pneumonia and ARDS. Placement of the tube too deep can result in only one lung being ventilated and can result in a pneumothorax as well as inadequate ventilation. During endotracheal tube placement, damage can also occur to the teeth, the soft tissues in the back of the throat, as well as the vocal cords.

    This procedure should be performed by a physician with experience in intubation. In the vast majority of cases of intubation, no significant complications occur.

    Exams and Tests

    The health care provider will do a physical examination, which may show:
    •Decreased breath sounds in the lungs
    •Rapid, shallow, or slowed breathing
    Tests are usually not necessary, but may include:
    •Bronchoscopy
    •Laryngoscopy
    •X-rays

    Managing airway obstruction

    What should you know about managing airway obstruction?
    Treatment depends on the cause of the blockage.

    Simple maneuvers (manual maneuvers)

    Jaw thrust
    Chin lift

    Artificial airway devices

    Oropharyngeal airway (OPA).
    Nasopharyngeal airway (NPA).
    Bag-mask ventilation
    Laryngeal mask airway
    Endotracheal tube

    Objects stuck in the airway may be removed with special instruments. A tube may be inserted into the airway (endotracheal tube) to help with breathing. Sometimes, an opening is made through the neck into the airway (tracheostomy or cricothyrotomy). If the obstruction is caused by a foreign body, such as a piece of food that has been breathed in, doing abdominal thrusts can save the person's life.

    Burns
    What are the classifications of burns?
    Rule of Nines for adult and child
    What causes burns?
    How long does it take for burns to heal?
    How are burns treated?
    What do I need to know about electrical and chemical burns?
    How are burns classified?
    What is the significance of the amount of body area burned?
    How important is the location of a burn?
    What about electrical burns?
    What about chemical burns?
    What are the potential complications of being severely burned?
    What is the prognosis of burn injury?
    Classification of Burns

    What are the classifications of burns?
    Burns are classified as first-, second-, or third-degree, depending on how deep and severe they penetrate the skin's surface.

    First-degree (superficial) burns
    First-degree burns affect only the epidermis, or outer layer of skin. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example. Long-term tissue damage is rare and usually consists of an increase or decrease in the skin color.

    Second-degree (partial thickness) burns
    Second-degree burns involve the epidermis and part of the dermis layer of skin. The burn site appears red, blistered, and may be swollen and painful.

    Third-degree (full thickness) burns
    Third-degree burns destroy the epidermis and dermis and may go into the subcutaneous tissue. The burn site may appear white or charred

    Fourth degree burns. Fourth degree burns also damage the underlying bones, muscles, and tendons. There is no sensation in the area since the nerve endings are destroyed..

    Here are further guidelines.
    www.qureshiuniversity.com/burns.html

    Tachycardia
    What is tachycardia?
    What are the signs and symptoms of tachycardia?
    What are the risk factors for tachycardia?
    What are the causes of tachycardia?
    How is tachycardia diagnosed?
    What are the treatment options for tachycardia?
    What are the possible complications of tachycardia?

    What is tachycardia?
    Tachycardia refers to an abnormally fast resting heart rate - usually at least 100 beats per minute. The threshold of a normal heart rate (pulse) is generally based on the person's age. Tachycardia can be dangerous; depending on how hard the heart has to work.

    In general, the adult resting heart beats between 60 and 100 times per minute (some doctors place the healthy limit at 90, so some of them may diagnose tachycardia at slightly lower than 100 beats per minute). When an individual has tachycardia the upper or lower chambers of the heart beat significantly faster - sometimes this happens to both chambers.

    When the heart beats too rapidly, it pumps less efficiently and blood flow to the rest of the body, including the heart itself is reduced. The higher-than-normal heartbeat means there is an increase in demand for oxygen by the myocardium (heart muscle) - if this persists it can lead to myocardial infarction (heart attack), caused by the dying off of oxygen-starved myocardial cells.

    Some patients with tachycardia may have no symptoms or complications. Tachycardia significantly increases the risk of stroke, sudden cardiac arrest or death.

    Our heart rates are controlled by electrical signals which are sent across heart tissues. When the heart produces rapid electrical signals tachycardia occurs.

    What are the signs and symptoms of tachycardia?
    A symptom is something the patient feels and reports, while a sign is something other people, such as the doctor detect. For example, pain may be a symptom while a rash may be a sign.

    When the heart beats too rapidly blood may not be pumped to the rest of the body effectively; this may affect organs and tissues which are deprived of oxygen. The following signs and symptoms of tachycardia are possible:
    Accelerated heart rate (fast pulse)
    Chest pain (angina) - chest pain or discomfort that occurs when the heart muscle does not get enough blood. Angina is more likely if the heartbeat is very fast and the heart is being put under a lot of strain.
    Confusion
    Dizziness
    Hypotension (low blood pressure)
    Lightheadedness
    Palpitations - an uncomfortable racing feeling in the chest, sensation of irregular and/or forceful beating of the heart.
    Panting (shortness of breath)
    Sudden weakness
    yncope (fainting)

    It is not unusual for some patients with tachycardia to experience no symptoms at all. In such cases the condition is typically discovered when the individual comes in for a physical examination or a heart-monitoring test.
    What are the risk factors for tachycardia? A risk factor is something which increases the likelihood of developing a condition or disease. For example, obesity significantly raises the risk of developing diabetes type 2. Therefore, obesity is a risk factor for diabetes type 2. As you will see below, there is some overlap between risk factors and causes.

    Tachycardia risk is increased if the patient has a condition which either damages heart tissue and/or puts a strain on the heart. The following conditions are linked to a higher risk of tachycardia:
    Age - people over the age of 60 have a significantly higher risk of experiencing tachycardia, compared to younger individuals.
    Anxiety
    Consuming large quantities of alcohol regularly
    Consuming large quantities of caffeine
    Genetics - people who have close relatives (e.g. parents) with tachycardia or other heart rhythm disorders have a higher risk of developing the condition themselves, compared to other individuals. Heart disease
    Hypertension (high blood pressure)
    Mental stress
    Smoking
    Using recreational drugs

    What are the causes of tachycardia?
    Tachycardia is generally caused by a disruption in the normal electrical impulses that control our heart's pumping action rhythm - the rate at which our heart pumps. The following situations, conditions and illnesses are possible causes:
    A reaction to certain medications
    Congenital (present at birth) electrical pathway abnormalities in the heart
    Congenital abnormalities of the heart
    Consuming too much alcohol
    Consumption of cocaine and some other recreational drugs
    Electrolyte imbalance
    Heart disease which has resulted in poor blood supply and damage to heart tissues, including coronary artery disease (atherosclerosis), heart valve disease, heart failure, heart muscle disease (cardiomyopathy), tumors, or infections.
    Hypertension
    Hyperthyroidism (overactive thyroid gland)
    Smoking
    Certain lung diseases
    Sometimes the medical team may not identify the exact cause of the tachycardia.

    Atria, ventricles and the electrical circuitry of the heart

    The human heart consists of four chambers:
    Atria - the two upper chambers; a left atrium and a right atrium.
    Ventricles - the two lower chambers; a left ventricle and a right ventricle.
    The heart has a natural pacemaker called the sinus node; it is located in the right atrium. The sinus code produces electrical impulses; each one triggers an individual heartbeat.

    The electrical impulses leave the sinus mode and go across the atria, making the atria muscles contract. This atria muscle contraction pushes blood into the ventricles.

    The electrical impulses continue to the atrioventricular node (AV node), a cluster of cells. The AV node slows down the electrical signals, and then sends them on to the ventricles. By delaying the electrical signals the AV node is able to give the ventricles time to fill with blood first. When the ventricle muscles receive the electrical signals they contract, pumping blood either to the lungs or the rest of the body.

    When there is a problem with the electrical signals resulting in a faster-than-normal heartbeat, the patient has tachycardia. The most common types of tachycardia include:
    Atrial fibrillation - When the two upper chambers - the atria - contract at an excessively high rate, and in an irregular way, the patient has atrial fibrillation. During atrial fibrillation the contractions of the two upper chambers of the heart are not synchronized with the contractions of the two lower chambers, causing rapid and irregular heartbeats. Atrial fibrillation is caused by chaotic electrical impulses in the atria; the AV node is bombarded with chaotic signals. An atrial fibrillation episode may last from a few hours to several days. Sometimes the episode does not go away without treatment. Most atrial fibrillation patients have some heart abnormality related to the condition.

    Atrial flutter - the atria beats rapidly, but regularly. It is caused by a circuit problem within the atria. The contractions of the atria are weak because of the rapid heartbeat. There is a rapid and sometimes irregular ventricular rate, caused by rapid signals entering the AV node. An atrial flutter episode may last a few hours or some days. Sometimes it may not go away until treated. Atrial flutter is sometimes a complication of surgery, but it also can be caused by various forms of heart disease. Patients with atrial flutter commonly experience atrial fibrillation too.

    Supraventricular tachycardias (SVTs) - any tachycardic (accelerated) heart rhythm originating above the ventricular tissue. The abnormal circuitry in the heart if usually congenital (present at birth) and creates a loop of overlapping signals. An SVT episode may last from a few seconds to several hours. In one SVT form the AV node splits the electrical signal in two, with one signal going to the ventricles while the other goes back to the atria. There may also be an extra electrical pathway from the atria to the ventricles, effectively bypassing the AV node and resulting in a signal going down one pathway and up the other.

    Ventricular tachycardia - abnormal electrical signals in the ventricles result in a rapid heart rate. The speed of the heart beat does not allow the ventricles to fill and contract properly, resulting in poor blood supply to the body. This type of tachycardia is frequently a life threatening condition and is treated as a medical emergency. Ventricular tachycardia is linked to heart muscle damage from a previous heart attack or cardiomyopathy (disease of the heart muscle).

    Ventricular fibrillation - the ventricles quiver in an ineffective way, resulting in poor blood supply to the body. If normal heart rhythm is not restored rapidly, blood circulation will cease and the patient will die. Patients with an underlying heart condition, or those who have been struck by lightning causing serious trauma may experience ventricular fibrillation. How is tachycardia diagnosed? A good doctor can usually diagnose has tachycardia and what type it is by asking the patient some questions regarding symptoms, carrying out a physical exam, and ordering some tests. These may include:

    Blood tests - these help determine whether thyroid problems or other substances may be factors contributing to the patient's tachycardia. Blood tests can also reveal whether the individual has anemia, or problems with kidney function, which could complicate some tachycardias. Serum electrolytes may also be tested to determine sodium and potassium levels.

    Electrocardiogram (ECG) - electrodes are attached to the patient's skin to measure electrical impulses given off by the heart. The impulses are recorded as waves and displayed on a screen (or printed). This test will also show any previous heart disease that may have contributed to the tachycardia. The abnormality of the heart action is generally obvious right away. The doctor will look for patterns to determine what type of tachycardia the patient has.

    Holter monitor - the patient wears a portable device which records all their heartbeats. It is worn under the clothing and records information about the electrical activity of the heart while the person goes about his/her normal activities for one or two days. It has a button which can be pressed if symptoms are felt - then the doctor can see what heart rhythms were present at that moment.

    Event recorder - This device is similar to a Holter monitor, but it does not record all the heartbeats. There are two types:

    One uses a phone to transmit signals from the recorder while the patient is experiencing symptoms.

    The other is worn all the time for a long time; sometimes as long as a month (it must be taken off when showering or having a bath).

    This event recorder is good for diagnosing rhythm disturbances that happen at random moments.

    Electrophysiological testing (EP studies)- This is an invasive, relatively painless, non-surgical test and can help determine the type of arrhythmia, its origin, and potential response to treatment.

    The test is carried out in an EP lab by an electrophysiologist, and makes it possible to reproduce troubling arrhythmias in a controlled setting. During an EP study:

    The patient is given a local anesthetic.

    After an initial puncture an introducer sheath is inserted into a blood vessel.

    A catheter is inserted through the introducer sheath and is threaded up the blood vessel, through the body and into the right chambers of the heart.

    The electrophysiologist can see the catheter moving up the body on a monitor.

    When it is inside the heart the catheter stimulates the heart and records where abnormal impulses start, their speed, and which normal conduction pathways they bypass.

    Treatments can be given to find out whether they stop the arrhythmia.

    The catheter and introducer sheaths are then removed, and the insertion site is closed up either by applying pressure to the site or with stitches.

    Tilt-table test - if the patient experiences fainting spells, dizziness or lightheadedness, and neither the ECG nor the Holter revealed any arrhythmias, a tilt-table test may be performed. This monitors the patient's blood pressure, heart rhythm and heart rate while he/she is moved from a lying down to an upright position.

    A healthy patient's reflexes cause the heart rate and blood pressure to change when moved to an upright position - this is to make sure the brain gets an adequate supply of blood.

    If the reflexes are inadequate they could explain the fainting spells, etc.

    Chest X-ray - the X-ray images help the doctor check the state of the individual's heart and lungs. A chest X-ray may also help a doctor determine whether any congenital heart defects are present. Other conditions that may explain the signs and symptoms might also be detected. What are the treatment options for tachycardia? Treatment options vary, depending on what caused the condition, the patient's age and general health, and some other factors. The aim is to slow down an accelerated heartbeat when it occurs, prevent subsequent episodes of tachycardia and reduce risk complications. In some cases all that is required is to treat the cause, as may be the case with hyperthyroidism (an overactive thyroid gland). In some cases no underlying cause is found and the doctor may have to try out different therapies.

    Ways to slow down a fast heartbeat:

    Vagal maneuvers - this is a maneuver which affects the vagal nerve. The vagal nerve helps regulate our heartbeat. Maneuvers may include coughing, heaving (as if you were having a bowel movement), and placing an icepack on the patient's face. If this does not stop the rapid heartbeat the patient may need an anti-arrhythmic medication.

    Medication - an anti-arrhythmic injection is administered to restore a normal heartbeat. This is done in a hospital. The doctor might prescribe an oral anti-arrhythmic drug, such as flecainide (Tambocor) or propafenone (Rythmol).

    Controlling tachycardia can be approached in two ways:

    The normal heart rhythm can be restored.

    The rate at which the heart beats can be controlled.

    Available drugs can do one of three things:

    Restore normal heart rhythm.
    Control the heart rate.
    Both restore normal heart rhythm and control the heart rate.
    Which anti-rhythmic medication to use depends on:

    The type of tachycardia.
    Other medical conditions the patient might have.
    Side effects of the chosen drug.
    How well the patient's condition responds to treatment.

    Sometimes a patient will need to take more than one anti-arrhythmic drug.

    Cardioversion - paddles or patches are used to deliver an electric shock to the heart. This affects the electrical impulses in the heart and restores normal rhythm. This is carried out in a hospital. Doctors say that cardioversion has a success rate of over 90% in early-diagnosed patients. Cardioversion may be used when emergency care is needed, or when other therapies have not worked. Prevention of episodes of tachycardia

    Radiofrequency catheter ablation - this treatment is generally used when the tachycardia is caused by an extra electrical pathway. Catheters enter the heart via blood vessels. Electrodes at the ends of the catheter are heated to ablate (damage) the extra pathway, stopping it from sending electrical signals. Radiofrequency catheter ablation is especially effective for patients with supraventricular tachycardia. This procedure may also be used for atrial fibrillation and atrial flutter.

    Researchers from the Asklepios Klinik St Georg, Hamburg, Germany demonstrated that catheter ablation use before implanting ICD (implantable cardioverter-defibrillator) minimizes ventricular tachycardia recurrence risk at two years. They reported their findings in The Lancet, January 2010 issue.

    Medications - when taken regularly anti-arrhythmic medications may prevent tachycardia. Patients may be prescribed other medications which may be taken in combination with anti-arrhythmics, for example, channel blockers, such as diltiazem (Cardizem) and verapamil (Calan), or beta blockers, such as propranolol (Inderal) and esmolol (Brevibloc).

    ICD (implantable cardioverter defibrillator) - the device, which continuously monitors the patient's hearbeat, is surgically implanted into the chest. The ICD detects any heartbeat abnormality and delivers electric shocks to restore normal heart rhythm.

    Surgery - sometimes surgery is needed to destroy an extra electrical pathway. The surgeon may create a pattern or maze of scar tissue. Scar tissue is a bad conductor of electricity. This procedure is generally only used when other therapies have not been effective, or if the patient has another heart disorder.

    Warfarin - for patients with either high or moderate risk of developing stroke or heart attack. Warfarin makes it harder for the blood to clot. Although Warfarin increases the risk of bleeding, it is prescribed for patients whose risk of stroke or heart attack is greater than their risk of bleeding. Patients need to have regular blood tests - sometimes, depending on the results of the blood tests, the Warfarin dosages need to be altered.

    It is crucial that the patient takes the Warfarin as directed by the doctor. As Warfarin can interact harmfully with many medications, it is vital that the patient and doctor check for this every time a new medication is prescribed or bought over the counter. A trained pharmacist will know which medications interact with Warfarin. Even alcohol and cranberry juice can affect Warfarin.

    Pradaxa (Dabigatran) has similar bleeding rates to warfarin, the FDA informed in November 2, 2012. Pradaxa is gradually becoming the medication of choice for patients with non-valvular atrial fibrillation, because unlike warfarin, it does not require regular blood tests for international normalized ratio monitoring, and offers the same efficacy results. However, Pradaxa is much more expensive, and when bleeding starts, it is easier to stop with warfarin. What are the possible complications of tachycardia? The risk of complications depends on several factors, including:
    The severity
    The type
    The rate of tachycardia
    The duration of tachycardia
    Whether or not other heart conditions are present

    The most common complications include:
    Blood clots - these significantly increase the risk of heart attack or stroke.
    Heart failure - if the condition is not controlled the heart is likely to get weaker. This may lead to heart failure. Heart failure is when the heart does not pump blood around the body efficiently or properly. The patient's left side, right side, or even both sides of the body can be affected.
    Fainting spells
    Sudden death - generally only linked to ventricular tachycardia or ventricular fibrillation

    Mathematics in human health care
    Mathematics in human health care

    Inventory accountant in the state.
    Questions you need to answer.

    How many road ambulances are there in the state?
    What types of ambulances are there in the state?
    What is the usually parking location of ambulances in the state?
    How many hospital emergency rooms are there in the state?
    What is the contact information of hospital emergency rooms in the state?
    How many hospital pharmacies are there in the state?
    How many emergency medical specialists (first responder) are there in the state?
    How many emergency medical specialists (emergency room) are there in the state?
    How many emergency technicians and paramedics are there in the state?
    How many hospital intensive care units are there in the state?
    How many other relevant staff are there in the state?
    How many computers with Internet relevant to emergency medical services are there in the state?
    What is the day, date, and address you are updating these facts in the state?

    What are examples of various emergency medical services in various states around the world?
    North American States
    1. Alabama (AL)

    2. Alaska (AK)

    3. Arizona (AZ)

    4. Arkansas (AR)

    5. Alberta (AB)

    6. British Columbia (BC)

    7. California (CA)

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    9. Connecticut (CT)

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    13. Hawaii (HI)

    14. Idaho (ID)

    15. Illinois (IL)

    16. Indiana (IN)

    17. Iowa (IA)

    18. Kansas (KS)

    19. Kentucky (KY)

    20. Louisiana (LA)

    21. Maine (ME)

    22. Maryland (MD)

    23. Massachusetts (MA)

    24. Michigan (MI)

    25. Minnesota (MN)

    26. Mississippi (MS)

    27. Missouri (MO)

    28. Montana (MT)

    29. Manitoba (MB)

    30. Mexico (MX)

    31. Nebraska (NE)

    32. Nevada (NV)

    33. New Hampshire (NH)

    34. New Jersey (NJ)

    35. New Mexico (NM)

    36. New York (NY)

    37. North Carolina (NC)

    38. North Dakota (ND)

    39. New Brunswick (NB)

    40. Newfoundland and Labrador (NL)

    41. Northwest Territories (NT)

    42. Nova Scotia (NS)

    43. Nunavut (NU)

    44. Ohio (OH)

    45. Oklahoma (OK)

    46. Oregon (OR)

    47. Ontario (ON)

    48. Pennsylvania (PA)

    49. Prince Edward Island (PE)

    50. Quebec (QC)

    51. Rhode Island (RI)

    52. South Carolina (SC)

    53. South Dakota (SD)

    54. Saskatchewan (SK)

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    56. Texas (TX)

    57. Utah (UT)

    58. Vermont (VT)

    59. Virginia (VA)

    60. Washington (WA)

    61. West Virginia (WV)

    62. Wisconsin (WI)

    63. Wyoming (WY)

    64. Yukon (YT)
      Asian States

    65. Albania

    66. Andorra

    67. Armenia

    68. Austria

    69. Azerbaijan

    70. Arkhangelsk Oblast

    71. Anhui Province

    72. Afghanistan

    73. Assam

    74. Arunachal Pradesh

    75. Andhra Pradesh

    76. Andaman and Nicober Islands

    77. Bangladesh

    78. Bhutan

    79. Brunei

    80. Belarus

    81. Belgium

    82. Bosnia and Herzegovina

    83. Bulgaria

    84. Bihar

    85. Bahrain

    86. Chechnya

    87. Croatia

    88. Cyprus

    89. Czech Republic

    90. Cambodia

    91. Chukotka Autonomous Okrug

    92. Chhattisgarh

    93. Daman and Diu

    94. Dadra and Nagar Haveli

    95. Denmark

    96. England

    97. Estonia

    98. East Timor

    99. Finland

    100. Fujian Province

    101. France

    102. Gujarat

    103. Goa

    104. Georgia

    105. Germany

    106. Gibraltar

    107. Greece

    108. Gansu Province

    109. Guangdong Province

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    162. Mongolia

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    222. Wales

    223. West Bengal

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    228. Zhejiang
      Africa

    229. Algeria

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    234. Botswana

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      Australia

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      Latin

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    307. Goiás

    308. Bolivia

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    311. Ecuador

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    315. Paraguay

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    317. Río Negro

    318. Santa Cruz

    319. Santa Fe Province

    320. Salta Province

    321. South Georgia

    322. Suriname

    323. Uruguay

    324. Venezuela

    Trauma and Gunshot wounds: What you need to know to save a life.
    Trauma is generally divided into penetrating or blunt trauma. Penetrating trauma refers to gunshot wounds, stab wounds, and injury from projectiles. Blunt trauma can include assaults, motor vehicle accidents, falls, explosions, and other force mechanisms.

    Whatever the cause of trauma, there are a few basic rules to remember. An easy way to remember the approach to an injured patient is the A, B, C, D, E’s; Airway, Breathing, Circulation, Disability, Exposure. See Table 1.

    TABLE 1
    The Basics What to evaluate Action to take
    A: Airway Assess the airway Look, listen, and feel Open the mouth and airway Remove any foreign bodies or loose teeth Use head tilt-chin lift or jaw thrust maneuver if cervical spine injury is suspected.
    B: Breathing Assess breathing Is the chest rising & falling? Provide assisted respirations if the patient is not breathing
    C: Circulation Check pulses Start CPR if you don’t feel a pulse
    D: Disability Is the victim able to talk? Is victim moving extremities? Prevent neurological injury by making sure not to unnecessarily move the patient, especially don’t turn the head.
    E: Exposure Look for all stab wounds and gunshot wounds in armpits, groins, etc. Direct pressure if bleeding wound Do not remove impaled objects.


    A. A for Airway refers to the victim’s mouth and breathing passage. In an unconscious patient, the tongue is the most common cause of obstruction of the airway. Simply positioning the victim can allow them to breathe. A clear breathing passage is vital because once this is blocked, the victim heart will eventually stop beating without oxygen.

    B. B refers to breathing – meaning is the patient actively breathing and is the chest rising and falling symmetrically with each breath. For example, if someone is stabbed in the chest and one side of their chest has no breath sounds and does not rise and fall, there is usually a serious problem such as a lung collapse.

    C. C stands for Circulation. Assessing circulation means assessing the pulse at the wrist, neck, or groin and getting a blood pressure if you have a BP cuff. If you can feel a pulse at the carotid artery, it means the blood pressure is at least 60. D. D refers to Disability or neurological deficit. For example, a victim shot in the neck or back may not be moving their arms or legs. This usually means the spinal cord has been injured and moving the patient can make it worse. All of the findings or what you observe about a trauma victim and spontaneous movements of extremities should be communicated to the hospital staff.

    E. E stands for Exposure. You never want to miss a gunshot wound or stab wound as this can have deadly consequences. It is very easy to miss a gunshot in someone’s armpit or between the buttocks. If you don’t specifically look there, you will miss it. Fully exposing the patient and checking everyone will ensure you haven’t missed anything.

    Where do people heavily bleed? How long does it take?

    Applying direct pressure on a bleeding wound is the most effective technique. This simple maneuver will almost always stop the bleeding.

    The average adult male has 5 liter of blood in the body. Typically blood pressure begins to drop (hypotension) when 20 – 30% is lost. Death can occur when 40% of blood loss occurs and the volume is not replaced. There are five areas where people can bleed large amounts causing shock. They are the chest, abdomen, pelvis/retroperitoneum, long bones (eg. Femur) and at the scene (bleeding from an open wound onto the floor).

    1. CHEST BLEEDING: Massive chest bleeding typically comes from the blood vessels that run from the center of the chest cavity up to the head and down to the abdomen. These large blood vessels called the aorta and the vena cava take blood to and from the heart. The heart and the lungs can also be involved and can bleed heavily. The rib cage can also bleed if one of the blood vessels underneath each rib is injured but this bleeding tends to be at a slower rate.

    2. ABDOMINAL BLEEDING: Abdominal bleeding can occur from large solid organs such as your liver, spleen or kidney as well as the blood vessels feeding the intestines. All of these internal organs have a rich blood supply and when injured can bleed large amounts. The bleeding to these structures is unable to be controlled in the field and these patients require emergent transfer to an acute care setting.

    3. PELVIS/RETROPERITONEAL BLEEDING: Pelvis/retroperitoneal bleeding occurs when the pelvis, which is really a ring of bones, is broken. The blood vessels that run along the bones are torn and bleed heavily. The retroperitoneum is the area behind the abdomen and your intestines. This is where the very large blood vessels, namely the aorta and inferior vena cava, are located. When either of these structures is injured, bleeding is often massive. Nature purposely placed these structures in the middle of our bodies and in front of the vertebral column to specifically

    5 protect them from injury. Not much can be done in the field to control this type of bleeding.

    4. LONG BONE BLEEDING: Bleeding from the long thigh bones of the leg can be significant. Bleeding can be controlled in extremity injuries with heavy manual compression. The typical mechanism is your leg being pinned into the dashboard during a motor vehicle crash. A gunshot wound to the leg can either fracture the femur or hit a major blood vessel causing hemorrhage. One can lose a liter and a half of blood into each thigh with a femur fracture. Reducing the fracture can help minimize this and “unkink” any blood vessels that provides circulation to the lower leg. 5. OPEN WOUND BLEEDING: If a person has not bleed into one of the internal cavities of the body such as the chest or abdomen or areas outlined above, the only other place the blood could have gone is on the floor. Open wound can bleed out and that’s why it is important to communicate to the doctors the amount of blood loss in the field.

    How to control bleeding

    Pressure, pressure, pressure. It cannot be overstated that simply putting direct pressure on a bleeding wound will stop or control most bleeding. You should press with whatever amount of force it takes for the bleeding to slow down and hopefully stop. If direct pressure doesn’t work, compressing the nearest artery feeding that area often works. This is why it is important to learn the basic anatomical path of the major blood vessels so that you know where to press and occlude them. If these steps don’t work, a tourniquet may be needed.

    Tourniquets

    The use of tourniquets is somewhat controversial and should not be a first line maneuver.

    GUNSHOT WOUNDS

    There are 3 main components of wounding with gunshot wounds.

    1. Penetration: Penetration refers to the flesh which is destroyed or disrupted by the passing projectile. A bullet fired at the abdomen must penetrate approximately 7 inches in order to reach the major blood vessels to cause significantly bleeding and sometimes instantaneous death.

    2. Cavitation is the second component and consists of a “shock-wave” like effect. Temporary cavitation can be up to 10 times the diameter of a medium to high velocity bullet. The permanent cavitation is the hole left by the bullet itself. Damage will depend on the elasticity of the organ or tissue. Muscle, blood vessels, lung and bowel are relatively elastic and therefore have a less permanent cavitation effect. Liver and brain on the other hand are relatively inelastic and cavitation becomes permanent resulting in significant damage.

    3. Fragmentation is the last component. Projectile fragments or secondary fragments such as bone are sent off and create their own paths through flesh. This is a major cause of tissue disruption with high velocity bullets.

    Never underestimate the size and trajectory of a gunshot wound. Gunshot wounds, with the exception of shotgun wounds, appear relatively small and unimpressive. But beware. The internal damage from the above mechanisms is quite significant. In addition, never assume a bullet travels in a straight line. We have seen hundreds of cases of the most 8 amazing trajectories. For example, I have seen a patient shot in the leg with the bullet sitting in his chest. Don’t necessarily focus on the wound itself.

    MANAGEMENT OF GUNSHOT WOUNDS

    Manual pressure should be applied if the wound is bleeding.

    We will now go over how to handle gunshot wounds from head-to-toe.

    GSW to HEAD Gunshot wounds to the head are typically fatal if the bullet crosses both of the brain hemispheres or hit the brain stem which is responsible for control of basic vitals. We have all seen miraculous cases with GSW to the head with victims walking around and talking. There is no real treatment in the field to treat this. Head elevation or seated positioning and rapid transport to a trauma center with neurosurgical capabilities is key. GSW to FACE & NECK Gunshot wounds to the face and neck are often troublesome. Since your face and neck have excellent circulation, bleeding is often heavy. In addition, the airway can become obstructed by blood, teeth, and swelling. Manual pressure should be applied to a bleeding wound and leave the victim in the upright position. Direct pressure should be strong enough to stop the bleeding. Avoid pressing over a large area as you can compromise blood flow to the brain or shift the trachea causing an airway obstruction. Emergency Medical Services often times place a cervical collar and back-board to immobilize a gunshot victim by protocol. However, the incidence of spinal cord injury caused by movement is exceedingly rare and therefore time should not be wasted with immobilization of the victim. Paralysis following gunshot wounds happens 9 instantaneously when the bullet rips through the spinal cord. It generally does not occur with moving fractures or other means.

    GSW to CHEST & BACK Gunshot wounds to the chest can hit a variety of organs. The lungs, heart, and major blood vessels can be struck and typically can be fatal if not immediately treated. A collapsed lung or pneumothorax will manifest with difficulty breathing. A tension pneumothorax is a collapsed lung that is building up pressure and causing collapse of adjacent organs. A hemothorax is blood in the chest cavity. Upon arrival to a trauma center, the trauma team will place a chest tube to relieve these conditions and drain blood. Sucking chest wounds occur when air is seen traveling in and out of a wound with each breath. Never completely occlude these sucking chest wounds as you can cause a build up of pressure within the chest and cause a life-threatening tension pneumothorax. Sucking chest wounds are very rare in the civilian setting with low velocity bullets but may be seen with medium and high velocity bullets. A three-sided tape technique with an occlusive dressing is indicated to manage these wounds.

    Direct pressure should be applied to a bleeding wound but it is often hard to compress chest bleeding as the structures that are bleeding are protected by the bony rib cage. If you are trained, needle decompression should be used if you suspect a tension pneumothorax. GSW to ABDOMEN Gunshot wounds to the abdomen can cause bowel damage as well as significant bleeding. Manual pressure with a dry dressing is indicated for an actively bleeding wound but oftentimes it is difficult to compress the internal bleeding source. This is why it is important to transport to a trauma center ASAP where a trauma surgeon can go in and operate immediately. GSW to the extremities Arm or leg gunshot wounds can bleed heavily if a blood vessel is struck. Direct manual pressure is indicated to initially control bleeding. An injured blood vessel can either bleed externally or sometimes clot and block blood flow to the remainder of the 10 extremity. Both are emergencies requiring a surgeon. You should press hard enough to stop the bleeding. Tourniquets, as described above, may sometimes be needed. Large skin defects, from for example shotgun wounds, may require topical clotting agents to help control bleeding. Typically, direct pressure is almost always enough.

    Attempting to stop massive bleeding after a gunshot wound.
    Here are further guidelines.
    What should investigators know about guns?
    http://www.qureshiuniversity.org/gunviolence.html

    Critical and noncritical medical emergency
    How do you differentiate between critical and noncritical medical emergency?
    How does a doctor conclude a situation is not a medical emergency?

    All these functions should be normal relevant to age.

    Answers to these questions will determine if this is a medical emergency.

    All these functions should be normal relevant to age.

    Is the patient able to talk normally?

    ___________________________

    Is the patient able to move his or her extremities normally?

    ___________________________

    Is the patient able to walk normally?

    ___________________________

    Are vital signs like consciousness (able to hear, see, talk), pulse, blood pressure, respiratory rate, and temperature relevant to age normal?

    ___________________________

    Are survival needs — food, clothing, housing, health care, transportation, communications, etc. – available from the state?

    ___________________________

    Is it correct that the patient is not agitated or sleepy?

    ___________________________

    Is it correct that the patient is not having acute functional loss or abbreation?

    ___________________________

    Is it correct that the patient is not in acute pain?

    ___________________________

    Is it correct that patient does not have a history of recent harms relevant to symptoms?

    ___________________________

    Is it correct that the patient is not a danger to him/herself or others?

    ___________________________

    Is it correct in the case of a female of child-bearing age who is not pregnant or does not having pregnancy-related complications if pregnant, and is not in labor if pregnant, or no post-delivery complications if she has delivered?

    ___________________________

    Is it correct that there is no woman’s sexual exploitation situation?

    ___________________________

    Is it correct that there is not a situation in which the individual does not know the whereabouts of family members?

    ___________________________

    Is it correct that there is not a situation of a child who does not have a caregiver?

    ___________________________

    (If the answer to any one of these questions is no, this is a critical medical emergency.)
    If yes, it is not a critical medical emergency.
    If the answers to all these questions are yes, this is not a critical medical emergency.

    If the answer to any one question is no, this is a critical medical emergency.
    Here is another method to differentiate between critical and noncritical medical emergency.

    What best describes this medical emergency situation?
    Individual survival needs — food, clothing, housing, health care, transportation, communications, etc. – are not available from the state.
    The patient is not able to talk normally.
    The patient is not able to move his or her extremities normally.
    The patient is not able to walk normally.
    The patient’s vital signs, like consciousness (able to hear, see, talk), pulse, blood pressure, respiratory rate, and temperature relevant to age are not normal.
    The patient is agitated or sleepy.
    The patient is having acute functional loss or abbreation.
    The patient is in acute pain.
    The patient has a history of new problems/complaints with recent harms relevant to symptoms.
    The patient is a danger to him/herself or others.
    The patient is a female of child-bearing age who needs medical termination of pregnancy.
    The patient has pregnancy-related complications.
    This is a woman’s sexual exploitation situation.
    This is an individual does not know the whereabouts of family members.
    This is a situation involving a child who does not have a caregiver.
    This is a situation with symptoms, signs, statements, questions, issues, or history that has been elaborated in the list of symptoms, signs, statements, questions, issues, or history of medical emergencies.
    (If the answer to any one of questions is yes, this is a medical emergency.)

    Trauma Ocular
    Injuries to the Eye
    Is there any sign of damage to the eye?
    Are there any signs of internal eye damage due to an injury?
    Is there any sign of permanent vision loss?
    Are there any optic nerve abnormalities?
    Is my peripheral vision normal?
    Is treatment necessary?
    How often should I schedule follow-up exams?


    What causes eye injuries?
    There are two types of trauma that are associated with the eye area.

    Blunt Trauma:

    Blunt Trauma involves receiving a direct blow to the eye from an object or apparatus that does not penetrate into the eye. Blunt trauma is most common in sports, where protective gear is not always worn on the eyes. This type of trauma can cause immediate decrease in vision if the retina is affected, and could even cause the retina to detach. It may also cause blood to accumulate in the front part of the eye causing high eye pressure (Hyphema).

    Injuries to the eye and surrounding structures can be caused by blunt trauma from a ball or fist, sharp trauma such as a stick or projectile, scratches such as with a fingernail or chemical trauma such as splash from a caustic substance like a cleaning materials or pool supplies.

    Penetrating Trauma:

    Penetrating Trauma occurs when an object either flies into the eye or penetrates the eye directly. Penetrating trauma can occur when exposed to small debris and particles while hammering, sawing, gardening or mowing the lawn, without wearing proper eye protection. This needs immediate attention in the emergency room as most likely xrays will be needed to locate the foreign penetrating object. Emergency surgery to close the cut of the eye and to remove the foreign object may be needed.

    Which part of the eye can be injured?
    Injuries to the eye can involve the skin and eyelids, the bones surrounding the eye, or the eyeball itself.

    What are some injuries to the eyelids?
    Eyelid injuries usually occur as a result of sharp trauma such as injuries from sticks or projectiles that occur during play. If the eyelid tissue becomes cut or torn it could involve not only the eyelid but the structures that drain tears out of the eye. Any laceration of the eyelid or the torn draining structure requires evaluation by an ophthalmologist and may require repair n the operating room using microsurgical techniques. Any injury to the eyelid can also be associated with injury to the eyeball so a timely complete examination of the eye must be performed to make certain there is no injury deeper than on the surface of the eye.

    How can the bones of the eye be damaged?
    Fractures to the bones around the eye usually occur from blunt trauma, such as a sports injury or a fall with injury to the nose and cheekbone, (see blow-out fracture). Fractures can be determined by performing x-rays or a CT scan and care must be taken to make certain that tissues surrounding the eye are not trapped in the fractures, as these injuries need prompt surgical treatment to prevent long-term complications such as double vision, loss of vision, and abnormal appearance.

    What are some common injuries to the eyeball itself?
    The front, clear surface of the eye called the cornea can sometimes be scratched, which results in pain, redness and tearing. The physician or eye doctor can make the diagnosis by placing a yellow dye called fluorescein into the eye, which will highlight the scratch. Treatment involves using antibiotic eye drops and, in severe cases, may require covering the eye with a patch to keep the eye quiet and prevent blinking. These injuries require close follow up with your ophthalmologist.

    What if the scratch goes deeper than the surface?
    Sometimes a sharp stick. shard of glass, or metallic object can actually cut the surface of the eye causing a laceration. This type of injury places the child at risk for permanent loss of vision (amblyopia or lazy eye). These lacerations must be repaired by an ophthalmologist promptly to prevent complications. Patching the sound eye may be required following repair to maximize vision potential.

    Can being struck in the eye with a ball or elbow during play cause damage inside the eye?
    Yes. For example, it is common for blunt trauma to cause bleeding in the eye, a condition called a hyphema. The bleeding in the eye can lead to increased pressure, which can cause permanent vision loss. Any child who is struck in the eye with the result of swelling of the eyelids, red eye, pain, redness, or watery discharge should be seen by an ophthalmologist as soon as possible.

    What do I do if a chemical or cleaning solution splashes into my child’s eye?
    The first thing to do any time any abnormal liquid gets in eyes is to immediately wash out the eye. Rinsing the chemical out of the eye will decrease the chance of long-term problems. If there is any eye pain, redness, discomfort, or watering, the child should be seen by an emergency room doctor or an ophthalmologist immediately. Bring the chemical or solution with you to the doctor’s office as this will help the doctor determine appropriate treatment.

    What are the most common causes of eye injuries in children?
    The most common cause of eye trauma occurs at school or during play. Wearing approved and tested eye and face protection is essential for preventing these injuries during sports. For example, no child should play hockey, be it ice or roller hockey, without wearing protective goggles or full face mask. Sports such as racquet ball or squash also require use of protective goggles at all times. Even in sports like baseball, eye injuries can be prevented by using batting helmets that protect the eye from a misdirected pitch.

    Do fireworks still cause eye injuries?
    Each year 1400 individuals sustain serious eye injury from fireworks that are used without appropriate supervision and precautions. Fireworks should only be used if approved for use in the home and children should never have access to either legal or illegal fireworks.

    Treatment:

    Treatment for eye trauma depends on the type and severity. If blunt trauma has caused a retinal tear or a complete detachment, surgery will most likely be required to prevent vision loss.

    If penetrating trauma has caused bleeding in other areas of the eye, infection could occur if not treated promptly. Intraocular foreign body may need surgery to be found and removed. Intraocular antibiotics may be administered. Above all get to the emergency room where proper exam, X rays and treatment can be started. There is an on-call ophthalmologist available at the Vidant Health Systems Hospital (in Greenville) Emergency Room 24/7/365 days a year.

    Prevention:

    While some eye trauma seems unavoidable, it is possible to reduce the effects of this trauma by always wearing suitable eye protection for the activity you are performing.

    Long Term Prognosis:

    This depends on the severity of the trauma however the trauma patient will need routine eye exams to look for delayed eye problems that may develop months to years later. These problems may include glaucoma, delayed retinal detachment, epiretinal membrane, sympathetic ophthalmia, uveitis, cataract and other problems. Once the acute eye problems are over, the 6 to 12 month exam schedule starts looking for these problems. Typically these exams are done by your regular eye doctor.

    Symptoms of Eye Trauma

    Symptoms of eye trauma may include:
    •Bruising (black eyes)
    •Cuts to the eyelid
    •Eye redness
    •Swelling
    •Bleeding between the cornea and iris, known as hyphema
    •Retinal detachment
    •Blurred or cloudy vision
    •Double vision

    How to recognize an eye injury

    The person has obvious pain or trouble seeing.

    The person has a cut or torn eyelid.
    One eye does not move as well as the other.
    One eye sticks out compared to the other.
    The eye has an unusual pupil size or shape.
    There is blood in the clear part of the eye.
    The person has something in the eye or under the eyelid that can't be easily removed.

    What to do for an eye injury

    For all eye injuries:
    DO NOT touch, rub or apply pressure to the eye.
    DO NOT try to remove the object stuck in the eye.
    Do not apply ointment or medication to the eye.
    See a doctor as soon as possible, preferably an ophthalmologist.

    If your eye has been cut or punctured:
    Gently place a shield over the eye. The bottom of a paper cup taped to the bones surrounding the eye can serve as a shield until you get medical attention.
    DO NOT rinse with water.
    DO NOT remove the object stuck in eye.
    DO NOT rub or apply pressure to eye.
    Avoid giving aspirin, ibuprofen or other non-steroidal, anti-inflammatory drugs. These drugs thin the blood and may increase bleeding.

    If you get a particle or foreign material in your eye:
    DO NOT rub the eye.
    Lift the upper eyelid over the lashes of your lower lid.
    Blink several times and allow tears to flush out the particle.
    If the particle remains, keep your eye closed and seek medical attention.

    In case of a chemical burn to the eye:
    Immediately flush the eye with plenty of clean water
    Seek emergency medical treatment right away.

    To treat a blow to the eye:
    Gently apply a small cold compress to reduce pain and swelling.
    DO NOT apply any pressure.
    If a black eye, pain or visual disturbance occurs even after a light blow, immediately contact your Eye M.D. or emergency room.
    Remember that even a light blow can cause a significant eye injury.
    To treat sand or small debris in the eye:
    Use eyewash to flush the eye out.
    DO NOT rub the eye.
    If the debris doesn't come out, lightly bandage the eye and see an ophthalmologist or visit the nearest emergency room. Specifics

    • Black Eye
    • Corneal Abrasions
    • Corneal Laceration
    • Eye Injuries at Home
    • Eye Injuries at Work
    • Eye Injuries in Construction
    • Eye Injuries in Sports
    • Hyphema
    • Macular Pucker From the National Institutes of Health (National Eye Institute)
    Blast-related ocular trauma
    Retinal Detachment Caused by Injury to Eye
    Fractures of the Orbit
    Lacerated Eyeball
    Eyelid Lacerations
    Corneal Abrasions and Corneal Foreign Bodies
    Intraocular Foreign Bodies
    Burns to the Eye
    Traumatic Iritis and Chemical Iritis
    Traumatic Glaucoma

    Scratched Eye (Corneal Abrasion)
    Penetrating or Foreign Objects in the Eye
    Caustic Foreign Substance in the Eye (Chemical Burn)

    Acid. As a general rule, acids can cause considerable redness and burning but can be washed out fairly easily. Alkali. Substances or chemicals that are basic (alkali) are much more serious but may not seem so because they don't cause as much immediate eye pain or redness as acids. Some examples of alkali substances are oven cleaners, toilet bowl cleaners and even chalk dust.

    Eye Swelling
    Subconjunctival Hemorrhages (Eye Bleeding)
    Traumatic Iritis
    Hyphemas and Orbital Blowout Fractures

    Depending on the severity of the trauma, surgery may be needed to repair parts of the eye, reattach the retina, restore the anatomy or keep an infection from causing permanent blindness.

    Vision Screening

    What is vision screening?
    Vision screening is an efficient and cost-effective method to identify children with visual impairment or eye conditions that are likely to lead to visual impairment so that a referral can be made to an appropriate eye care professional for further evaluation and treatment.

    How is vision screening performed?
    There are a number of methods used to screen a child's vision. The method chosen is largely dependent on the age of the child being screened and the experience of the examiner. Several methods of vision screening are discussed below:

    Inspection of the eye, pupils and red reflex

    This method can be used on children of all ages. At each well child visit, the examiner uses a flashlight to inspect the eyes for abnormality of shape or structure and to detect irregularity in pupil shape. The pupil constricts (become smaller) in bright light and dilates (become larger) in the dark, and both pupils are the same size. An ophthalmoscope is used to observe the red reflex of the eye. The red reflex is a reflection from the lining of the inside of the eye that causes the pupil to look red in photographs. The red reflex should be bright in both eyes and equal.

    Photoscreening

    This is an automated technique that uses the red reflex to identify many types of eye problems. An advantage of this screening is that it is quick and thus useful in very young children. The newest generation of photoscreeners provide immediate information about the eye condition. There may be an extra fee for this testing when performed at a doctor's office. Some community screenings use this method.

    Corneal light reflex testing

    This simple test can be performed on any child using a penlight. As a child focuses on a penlight, the position of the light reflection from the front surface (cornea) of the eye is observed. The test is accurate only if the child looks directly at the light and not to the side. Normally the corneal light reflex is in sharp focus and centered on both pupils. The test is abnormal if the corneal light reflex is not crisp and clear or if it is "off-center."

    Cover testing

    This test detects misalignment of the eyes. While the child focuses on a target, the examiner covers each eye sequentially to look for a "shift" in the alignment of the eyes. This test requires a cooperative child (usually 3 years or older) and an experienced examiner.

    Subjective visual acuity testing

    The use of an eye chart requires a cooperative child, so successful testing is greatest with children 3 years and older. Since it is the only screening method that directly measures visual acuity, it is the preferred exam for older children. Modifications of the adult eye chart make it easier to test children. For example, the 20-foot testing distance is often shortened to 10 feet, and pictures or shapes can be used in place of letters. It is important to test each eye separately and to verify that the child is not "peeking" with the other eye.

    What kinds of eye problems can be detected on a vision screening?
    The main goal of vision screening is to identify children who have or are at risk of developing amblyopia, which can lead to permanent visual impairment unless treated in early childhood. Other problems that can be detected by vision screening include strabismus (eye misalignment), cataracts, glaucoma, ptosis (drooping eyelid), refractive errors such as myopia ("nearsightedness"), hyperopia ("farsightedness") and astigmatism, and other more serious conditions such as tumors or neurological diseases.

    Who performs vision screening?
    Pediatricians, family practitioners, nurses and technicians can perform vision screening at regular well care office visits. In addition, many day care programs, churches, schools and health departments offer vision screening programs for children.

    At what age should a child have his or her vision screened?
    Vision screening is most effective when performed periodically throughout childhood. The earlier a problem is detected, the better the chance to obtain maximal vision through appropriate treatment. The first vision screening takes place in the newborn nursery when the doctor or practitioner inspects the newborn's eye, pupil and red reflex. The child's practitioner continues to perform age appropriate vision screenings throughout infancy and childhood

    In some states a documented vision screening or comprehensive eye examination is required before beginning school.

    What is the difference between vision screening and a comprehensive eye examination, and which is more appropriate for most children?
    Vision screening is more efficient and cost effective (which allows many more children to be examined) than a complete examination on every child. Only about 2 to 4% of children have an eye problem that requires treatment, so it is not practical to perform a comprehensive eye examination on every child. In addition, some problems are missed on a one-time comprehensive eye examination, so it is preferable to have several screenings performed over time. Also, mandated comprehensive eye examinations likely result in glasses being prescribed unnecessarily for many children.

    Nevertheless, if a child has known risk factors for eye disease, if there is a family history of pediatric eye disease, or if a child has signs or symptoms suspicious for a vision problem, it is reasonable and appropriate for a child to have a comprehensive eye examination.

    What if a child fails his or her vision screening or cannot cooperate for vision screening?
    If a child fails a vision screening at any age, the child should be referred for a comprehensive eye examination. By age 3 or 4 years, most children are able to cooperate for subjective visual acuity testing using an eye chart. If a child is unable to cooperate for visual acuity testing at age 3, a second attempt should be made within 6 months, if the child is age 4, a second attempt should be made within one month. If retesting is impossible or inconclusive, then the child should be referred for a comprehensive eye examination.

    Techniques for Pediatric Vision Screening

    Age

    Tests

    Referral Criteria Comments

    Newborn to 12 months

    • Ocular history
    • Vision assessment
    • External inspection of the eyes and lids
    • Ocular motility assessment
    • Pupil examination
    • Red reflex examination
    • Refer infants who do not track well after 3 months of age.
    • Refer infants with an abnormal red reflex or history of retinoblastoma in a parent or sibling.

     

    12 to 36 months

    • Ocular history
    • Vision assessment
    • External inspection of the eyes and lids
    • Ocular motility assessment
    • Pupil examination
    • Red reflex examination
    • Visual acuity testing
    • Objective screening device “photoscreening”
    • Ophthalmoscopy
    • Refer infants with strabismus
    • Refer infants with chronic tearing or discharge.
    • Refer children who fail photoscreening.

    36 months to 5 years

    • Ocular History
    • Vision assessment
    • External inspection of the eyes and lids
    • Ocular motility assessment
    • Pupil examination
    • Red reflex examination
    • Visual acuity testing (preferred) or photoscreening
    • Ophthalmoscopy

         Visual acuity thresholds

    • Ages 36-47 months:  Must correctly identify the majority of the optotypes on the 20/50 line to pass.
    • Ages 48-59 months:  Must correctly identify the majority of the optotypes on the 20/40 line to pass.
    • Refer children who fail photoscreening.

    5 years and older*

     

     *Repeat screening every 1-2 years after age 5.

     

    • Ocular history
    • Vision assessment
    • External inspection of the eyes and lids
    • Ocular motility assessment
    • Pupil examination
    • Red reflex examination
    • Visual acuity testing
    • Ophthalmoscopy
    • Refer children who cannot read at least 20/32 with either eye. Must be able to identify the majority of the optotypes on the 20/32 line.
    • Refer children not reading at grade level.


    Eye Conditions
    A
    Abnormal Head Position
    Accommodative Esotropia
    Achromatopsia
    Adjustable Sutures in Strabismus Surgery
    Adult Strabismus
    Albinism
    Allergic Conjunctivitis
    Amblyopia
    Amblyopia (Hebrew)
    Anatomy of the Eye
    Anesthesia for Adults Having Eye Surgery
    Anesthesia for Children Having Eye Surgery
    Aniridia
    Anisocoria and Horner's Syndrome
    Anisometropia

    B

    Blepharitis
    Blowout Fracture
    Brown Syndrome

    C

    Capillary Hemangioma
    Cataract
    Cellulitis
    Chalazion
    Coats' Disease
    Coloboma
    Color Blindness
    Conjunctivitis
    Convergence Insufficiency
    Corneal Abrasions
    Cortical Visual Impairment
    Cranial Nerve Palsy

    D

    Dermoid Cyst
    Diabetes Mellitus and Diabetic Retinopathy
    Difference between an Ophthalmologist, Optometrist and Optician
    Dilating Eye Drops
    Dissociated Vertical Deviation
    Down Syndrome
    Duane Syndrome

    E

    Endophthalmitis
    Enucleation
    Esotropia
    Excessive Blinking in Children
    Exotropia
    Eye Muscle Problems in Children and Adults:A Guide to Understanding
    Eye Safety

    F

    Fetal Alcohol Syndrome
    Fourth Nerve (Superior Oblique) Palsy

    G

    Glasses Fitting for Children
    Glasses for Children
    Glaucoma for Children

    H

    Headaches in Children
    Herpes Eye Disease
    Hyphema

    I

    Idiopathic Intracranial Hypertension (Pseudotumor Cerebri)
    Infantile Esotropia
    Intraocular Lens Implant (IOL)
    Iritis

    J

    Juvenile Idiopathic Arthritis/Eye Problems and Juvenile Idiopathic Arthritis

    K

    Keratoconus
    L

    Learning Disabilities
    Leber's Congenital Amaurosis
    Leukocoria

    M

    Marfan Syndrome
    Meibomian Gland Dysfunction and Treatment
    Molluscum Contagiosum
    Monocular Elevation Deficiency/ Double Elevator Palsy
    Myasthenia Gravis

    N

    Nasolacrimal Duct Obstruction
    Neurofibromatosis
    Nystagmus

    O

    Ocular Injury
    Oculomotor Apraxia
    Optic Nerve Atrophy
    Optic Nerve Drusen
    Optic Nerve Hypoplasia
    Optic Nerve Pit
    Optic Neuritis
    Orthoptist/ Orthoptics

    P

    Patching Tips for Parents
    Pediatric Low Vision
    Pediatric Ocular Trauma
    Pediatric Ophthalmologist
    Photoscreening
    Pseudostrabismus
    Pterygium
    Ptosis

    R

    Refractive Errors in Children
    Retinitis Pigmentosa
    Retinoblastoma
    Retinopathy of Prematurity
    Retinoscopy
    Rubinstein-Taybi Syndrome

    S

    Shaken Baby Syndrome
    Sixth Nerve Palsy
    Stickler Syndrome
    Strabismus
    Strabismus Measurements
    Strabismus Surgery
    Sturge-Weber Syndrome

    T

    Third Nerve Palsy
    Thyroid Eye Disorders
    Toxoplasmosis
    Trichiasis

    V

    Vision Screening
    Vision Screening Recommendations
    Vision Therapy

    W

    Williams Syndrome
    Emergency Diagnosis and Treatment

    Life support
    Life support refers to the treatments and techniques performed in an emergency in order to support life after the failure of one or more vital organs.

    Techniques

    There are many therapies and techniques that may be used by clinicians to achieve the goal of sustaining life. Some examples include:

    Feeding tube
    Total parenteral nutrition
    Mechanical ventilation
    Heart/Lung bypass
    Urinary catheterization
    Dialysis
    Cardiopulmonary resuscitation
    Defibrillation
    Artificial pacemaker

    Cardiopulmonary Resuscitation (CPR)
    Basic life support programs
    Advanced Cardiovascular Life Support (ACLS)
    Advanced trauma life support

    EMS Medical Equipment
    Ambulance Stretcher
    Ambulance supplies
    Medical Equipment: Trauma Cases
    Endotracheal Intubation Equipment
    Patient handling
    Pediatric equipment
    Vascular access equipment
    Other EMS-related medical supplies.
    Ambulance Stretcher
    Ambulance Cots


    Endotracheal Intubation Equipment
      Laryngoscope
      Endotracheal Tube
      10 mL Syringe
      Stylet
      Bag-valve-mask device
      Suction
      Bite block
      Magill forceps
      Tape/Tube holder
      ETCO2 Detector (capnography)
      Esophageal Detector Device (EDD)
    Lifting and Moving Patients

    Cervical Traction Collar

    Neck Collars Come In A Variety Of Support Styles And Functions

    Here are further guidelines.

    Emergency medical room diagnosis and treatment.
    A–Z alphabetical listing of human health emergency symptoms and signs.
    Emergency Medical Department in a hospital in the state.
    Emergency room (medical)
    Patient assessment

    Reversible Causes of Cardiac Arrest: H's and T's
    7 H's and 6 T's: pnemonic for mechanisms
    * hypoxia
    * hypovolemia
    * hyperkalemia
    * hypokalemia
    * hypoglycemia
    * hypothermia
    * hydrogen ions (acidosis)
    * thrombosis (MI)
    * tension pneumothorax
    * tamponade
    * toxins/therapeutics
    * thromboembolism
    * trauma


    The “H’s and T’s” commonly associated with pre-arrest and cardiac arrest algorithms are critical since they are potentially reversible causes of arrest in adults and children. In any arrest situation, the clinician must consider these conditions and treat them when they occur. Of course, treatment of the arrhythmia should NOT be delayed in an attempt to determine if one of these conditions exist.

    The H’s and T’s include:

    1. Hypovolemia – This is a common problem in the presence of trauma or dehydration. During the resuscitation, the clinician will see a rapid heart rate and, usually, a narrow QRS. Treatment should include a large bore IV or IO for rapid infusion of normal saline or lactated Ringer's solution. Be aware that in cases of blood loss, whole blood or packed cells should be considered for treatment since large amounts of other fluids may lead to hemodilution and less hemoglobin carrying capacity.
    2. Hypoxia or hypoxemia – Although early intubation is no longer the American Heart Association’s recommendation, if hypoxemia is the suspected or known cause of arrest, early intubation should be done. During resuscitation, the clinician will typically see a slow heart rate with circumoral cyanosis. Definitive treatment includes a patent airway, effective ventilation, and oxygen administration.
    3. Hydrogen Ion excess (Acidosis) – In general, if acidosis is present, the clinician may see low amplitude QRS complexes on the ECG. Normal pH is 7.35-7.45. When the pH goes down with a low oxygen level and high carbon dioxide level, a state of respiratory acidosis exists. Treatment for respiratory acidosis is intubation and airway management with hyperventilation. If the pH and bicarbonate levels are both low, a state of metabolic acidosis exists. If the problem is metabolic acidosis, treat with sodium bicarbonate 1mEq/kg.
    4. Hypoglycemia – A blood glucose level less than 60mg/dl in an arrest situation should be treated with 25 grams of dextrose (D50).
    5. Hypokalemia/Hyperkalemia – Electrolyte imbalances can lead to errors in cellular metabolism and ECG abnormalities. Hypokalemia will present as flattened T waves and the appearance of a U wave. The QRS may widen which can result in a wide complex tachycardia. Magnesium and potassium supplementation will help to correct hypokalemia. In the case of hyperkalemia, the clinician will see peaked T waves with a widened QRS. The clinician should consider treatment with calcium chloride, sodium bicarbonate, and glucose with insulin.
    6. Hypothermia – Hypothermia is typically preceded by exposure to cold temperatures. This condition should be treated by rewarming and a cardiac arrest patient should not be considered dead until he is warm and dead.
    7. Tension Pneumothorax – A clinician should suspect tension pneumothorax when there is asymmetrical chest movement or when breath sounds are absent on one side. The pneumothorax can cause heart compression leading to a slow heart rate with narrow complexes on the ECG. Treatment should include immediate needle decompression or thoracostomy.
    8. Tamponade (Cardiac) – There are several mechanisms of injury that can lead to cardiac tamponade: trauma and infection are two of the major causes. Typically, a clinician may notice muffled heart sounds, jugular vein distention, low blood pressure, and a rapid rate with narrow QRS complexes on the ECG. Treatment should be pericardiocentesis.
    9. Toxins – Accidental or intentional ingestion of toxins including prescription or over-the-counter medications is usually diagnosed by patient or family history. On the ECG, the clinician will usually see a prolonged QT interval. Treatment for toxins must be based on the overdose agent.
    10. Thrombosis (pulmonary embolus) – A pulmonary thrombosis/embolus (blood clot in the lung) is extremely difficult to diagnose without a ventilation/perfusion scan. The clinician will typically see a rapid heart rate with narrow QRS complexes on the ECG. Depending on the cause of the pulmonary thrombosis, treatment may include fibrinolytics or surgical embolectomy.
    11. Thrombosis (acute MI) – Finally, a blood clot in the heart that results in an acute myocardial infarction will cause the ECG to be abnormal. Treatment may include medications (fibrinolytics), cardiac stents, or cardiac surgery.

    Itching of a Human Being
    What is itching of a human being?
    Itching or an itch is a sensation that causes the desire or reflex to scratch.

    What is another word for itching?
    Pruritus

    What are the causes of itching in human beings?
    There are more than 70 causes of itching in human beings.
    Www.qureshiuniversity.com/Itching.html

    Bed bug symptoms and signs

    What are the symptoms and signs of bed bugs on the human body?
    Itching of the human body.
    Itching with red bites on the human body.
    Itching with uncomfortable sleep.
    Itching with rust spots on bedsheets.

    If these symptoms and signs are not there, do not conclude or diagnose a bed bug infestation on the human body.
    You will get charged with unprofessional conduct for reaching the wrong conclusion or diagnosis for a human being.

    As of October 5, 2016, Americans did not know how to diagnose and treat bed bugs relevant to human beings.
    Criminals have been placed in public health and individualized human healthcare and similar settings.
    International supervision, including of human healthcare, is essential 24 hours a day, 7 days a week, for all American states.

    When should you contact a medical professional?
    Call your healthcare provider if you have severe itching.
    Itching does not go away.
    Itching cannot be easily explained, controlled, or treated with home care.

    When is itching a medical emergency?
    Itching is so intense that you are unable to sleep.
    Itching is so intense and continuous that you feel extremely uncomfortable.
    Itching with abnormal vital signs, which happens in severe anaphylaxis.
    These examples are all medical emergencies.
    There are more than 70 causes of itching.
    The remaining causes all are non-emergencies.

    What is the epidemiology or number of cases of human beings who report itching globally every year?
    Approximately 280 million people globally, or 4% of the population, have difficulty with itchiness.
    This information was compiled and reported on October 7, 2016.
    2-3% of the population suffer from psoriasis.

    What is the treatment of itching of a human being?
    Home care.
    Primary healthcare setting of treatment.
    Medical emergency room treatment.

    Treat the underlying cause.
    There are more than 70 causes of itching of human beings.
    If medication is required, the dosage of medication depends on the age of the person.

    How do you do home care of itching of a human being?
    Take a look at this.
    www.qureshiuniversity.com/itching.html

    A variety of over-the-counter and prescription anti-itch drugs are available. Some plant products have been found to be effective anti-pruritics, whereas others are not. Non-chemical remedies include cooling, warming, and soft stimulation.

    A specific physician in Internet human healthcare, home care, primary health care, or medical emergency room must ask these questions of a local pharmacist ahead of time.

    What are the different types of Antipruritc Drugs?
    There are four types:
    Antihistamines such as Diphenhydramine
    Topical Corticosteroids such as Hydrocortisone Topical Cream
    Local Anesthetics such as Benzocaine Topical Cream
    Counterirritants such as Menthol, Mint Oil, or Camphor

    What types of topical anti-pruritics in the form of creams and sprays are available over the counter?
    Topical Corticosteroids such as Hydrocortisone Topical Cream

    What types of anti-itch drugs are available in local pharmacy?
    Oral anti-itch drugs also exist and are usually prescription drugs.

    The active ingredients usually belong to the following classes:
    Antihistamines, such as diphenhydramine (Benadryl)
    Corticosteroids, such as hydrocortisone topical cream; see topical steroid
    Counterirritants, such as mint oil, menthol, or camphor
    Crotamiton (Eurax), an anti-pruritic agent available as a cream or lotion, is often used to treat scabies. Its mechanism of action remains unknown. Local anesthetics, such as benzocaine topical cream (Lanacane)

    In a medical emergency room setting, when severe itching due to anaphylaxis occurs with abnormal vital signs, an intravenous antihistamine has to be given with a dosage relevant to the person’s body weight.

    Questions the medical emergency room supervisor/medical emergency physician must answer.

    What type of intravenous antihistamine is available in the medical emergency room?
    Where is it?


    Diphenhydramine injection (Benadryl) is an antihistamine used to treat life-threatening allergic reactions (anaphylaxis).
    Diphenhydramine injection (Benadryl) or the equivalent must be available in every medical emergency room.

    Medical Emergency Issues
    Facts from every medical emergency room inside or outside the state that must be displayed via the Internet.
    Where are the guidelines for existing, in training, and/or aspiring medical emergency room physicians and medical emergency responder physicians through the Internet as well as other medical emergency staff?
    You can circulate these resources: http://www.qureshiuniversity.com/medicalemergency.html

    Who is among the staff in this specific medical emergency room?
    What is the mailing address of this medical emergency room in the state?


    Who’s who among these professionals in this medical emergency room?
    Physician, medical emergency room, course director
    Physician, medical emergency room, existing
    Physician, medical emergency responder, existing
    Physician, medical emergency room, in training
    Physician, medical emergency responder, aspiring
    Physician, medical emergency room, in training
    Physician, medical emergency room, aspiring
    Other staff connected to a specific medical emergency room inside or outside the state.

    Questions medical emergency room physicians must answer ahead of time.
    Can you elaborate on who’s who in this medical emergency room?
    What emergency medical equipment is available in the medical emergency room?
    What topical, oral, and intravenous emergency medications are available in the medical emergency room?
    How many total existing medical emergency room physicians have rotation duty at this medical emergency room?
    What is the profile of other staff and supervisors in this medical emergency room?

    Locations and number of medical emergency rooms in every state.
    What are the locations and number of medical emergency rooms in every state?
    State department of public health and state department of health must display these facts via the Internet.

    Crash Cart Supply & Equipment Checklist


    Emergency Crash Cart
    All in one Carts
    Infinity
    PC Carts
    Laptop Carts
    Tablet Carts
    All in one pc carts
    Carts Medication Carts
    Medication Carts Large Screen, Large Format Carts
    Large Screen Carts Specialist Carts
    Specialist Carts

    What is in a crash cart?
    There is a basic list that all crash carts contain. All carts contain:
    •Basic airway equipment including bag valve masks, oral and nasal airways, oxygen masks and nasal cannulas, Magill forceps •Intravenous access equipment (or Intraosseous) including angiocaths, IV tubing and IV fluid. If the facility elects to utilize intraosseous access for emergency medications, then a drill and needles must be included.
    •Medications utilized in the treatment of cardiac arrest including Epinephrine and Amiodarone.
    •Medications utilized to treat cardiac dysrhythmias including Adenosine, Cardiazem, a Beta Blocker (usually Lopressor), and Atropine.
    •Monitor equipment with a defibrillator or an AED
    •Medications to treat allergic reactions such as Epi Pens, Solumedrol and Benadryl
    •Aspirin 81mg PO
    •Nitroglycerin spray or 0.4mg tablets

    Equipment

    ? Airway (oral and nasal) all sizes
    ? McGill forceps, large and small
    ? King Airway Set (3) Eliminates the need for Laryngoscope and Endotracheal tubes
    ? Bag Valve Mask (Adult and Pediatric)
    ? Nasal Cannula
    ? Non Rebreather Oxygen Face Masks (3 sizes)
    ? IV Start Packs
    ? Normal Saline Solution (1000ml bags)
    ? IV Tubing
    ? Angiocaths (various sizes)
    ? 10ml Normal Saline Flush Syringes (3)
    ? Gauze
    ? Alcohol Preps
    ? Monitor with Defibrillator (preferred) or AED
    ? Syringe nasal adaptor (nasal narcan atomizer)

    Drugs

    ? Aspirin 81mg Tablets
    ? Nitroglycerin Spray or 0.4mg tablets
    ? Dextrose 50% (Dextrose 25% if treating pediatrics)
    ? Narcan 1mg/ml (6)
    ? Epinephrine 1:10,000 Abbojet (3)
    ? Atropine Sulfate 1mg Abboject (3)
    ? Amiodarone 150mg Vial (4)
    ? Epi Pen (2)
    ? Epi Pen Jr (2)
    ? Solumedrol 125mg Vial
    ? Benadryl 50mg Vial (2)
    ? Adenosine 6mg (4)
    ? Lopressor 10mg (2)
    ? Cardiazem 20mg Vial (2)
    ? Pronestyl (Procainamide) 1g in 10 ml 100mg/ml Vial (1)

    Why a Crash Cart?
    Any environment in which a patient may unexpectedly experience a medical emergency needs to have the equipment to deal with that emergency efficiently. A crash cart contains the equipment and medications that would be required to treat a patient in the first thirty minutes or so of a medical emergency. Although crash carts can differ somewhat depending upon their location, the basic crash cart will contain similar equipment.

    Who need a crash cart?
    Any facility that treats patients who have the potential to have a sudden deterioration in their condition should have a crash cart available. State Regulatory agencies require certain facilities to have a crash cart, but they are recommended for many more. This would include hospitals, outpatient surgery centers, urgent care centers, and all centers where conscious sedation is performed. Nursing homes who provide treatment for patients in cardiac arrest until EMS arrives would also have a need for a crash cart. Physician offices who perform certain diagnostic testing such as Cardiac stress testing or stress Echocardiogram also must have a crash cart available.

    Additionally, carts being utilized for specialized areas may add or subtract from the basic list. Depending upon the specialty of the facility, the following may be added:
    •Endotracheal intubation equipment if anesthesia personnel are present in the facility
    •King Airways – in facilities without anesthesia personnel or as a bail out airway for the patient with a difficult airway
    •Narcan – to reverse the effects of narcotics in facilities where narcotics or sedation is used
    •Additional antiarrhtyhmics – particularly in physician offices who do cardiac stress testing

    Maintenance of Crash Cart

    The worst thing ever is to reach for a piece of emergency equipment or an emergency medication and find it inoperable or expired. It is important that the crash cart be checked regularly and maintained so that its contents are there when needed.

    Follow is a maintenance routine that should be completed at least monthly:
    Expiration dates on medications should be checked on the first day of the month
    Expired medications should be promptly removed and replaced
    The defibrillation pads on the AED or the defibrillator should be checked for expiration date
    The battery charge on the monitor and/or AED should be checked and documented

    Region-Specific Information

    State/provincial departments of health may amend these requirements.

    What is the standard time limit for removing medications from Crash cart?
    As far as I aware to remove medications before 90days of expiry. If this answer is correct then what is reason for removing before 90 days?

    Why cant we remove before 30 days?
    Medications are acceptable up until the day of expiration (normally the last day of the month in which they expire) The habit of removing them 90 days ahead came from when facilities would move medications before they expired to units that were more likely to utilize them before expiration.

    What will happen if you do not diagnose and treat a medical emergency properly?
    It can lead to death.
    It can lead to disability.
    It can lead to other harms.
    It can lead to medical malpractice.
    It can lead to legal malpractice.
    If this is not a medical emergency, it can be a medical disability or prolonged intentional enforced harms.
    Is there any medical disability, non-emergency problem or prolonged intentional enforced harms? If yes, a follow-up is required via e-mail, call, postal mail, or a doctor’s appointment.
    Last Updated: October 23, 2017