MDMA: also known as Ecstasy, E, X (or for those keeners…3,4-methylenedioxymethamphetamine)

One of the most commonly used substances in the club scene, primarily for its stimulatory effects, euphoric properties and emotional openness. MDMA is usually taken in pill form but can be mixed with a variety of other substances.  Not surprisingly as it is mostly a stimulant, signs of intoxication are dilated pupils, tachycardia, hyperthermia, sweating, tremor and decreased LOA.  As far as medical cautions dehydration is the key component of a bad night on MDMA.

FUN FACT: Patients who are also on SSRIs/SNRIs/MAOIs run the risk of serotonin syndrome – beware of extreme hyperthermia and seizures.

KETAMINE: also known as K, Ketalar, Special K

Although classically used as a horse tranquilizer, ketamine has become a staple in the club scene for its dissociative properties.  Most commonly found in a powder form, it can be snorted, ingested and injected.  In small doses it causes relaxation and auditory/visual sensations.  In larger doses (aka a K hole) patients can become catatonic and even progress to apnea.  These patients need to be monitored very closely with special attention to their airway.  Luckily these symptoms are self-limited (~20-30minutes) as ketamine has a short half-life.

FUN FACT: Contrary to popular belief giving someone who is in a k-hole sugar will NOT make them come out of it any sooner.

GHB: also known as Gamma Hydroxy Butyrate, G, Liquid E, Liquid X

In it’s pure form it is a clear, colourless, salty liquid but can be coloured or made into a powder.  It is used for its euphoric properties BUT due its small therapeutic index the amount patients need to get their ideal high isn’t that much less than they need before they black out.  Watch for altered LOA, bradycardia, bradypnea, hypotension and seizures.  GHB can also be used maliciously for the means of sexual assault.

FUN FACT:  Prior to 2000 GHB was legally sold in Canada at health food stores as a sleeping aid.
Brodie Nolan is a 4th year medical student at the University of Toronto. Brodie has 6 years of experience as an Emergency Medical Responder, and has interests in both pre-hospital care research and Emergency Medicine.

Have you guys heard the one about the fire fighter, the police officer or the paramedic? Of course you have! We all have, and most of the time, it’s all in good fun.  As services that work together we poke fun at each other, but when these jokes and shots turn into resentment, arguments, even anger and hatred, they’ve gone too far. There is frustration and unwillingness to help each other, competition and even fighting between services. And who suffers the most from these disputes? The people we are there to help, patients and others in need.

Now I know it is a bit extreme to blame any inter-service rivalry on jokes alone, when there are a wide variety of factors at play.  That said, these jokes often highlight underlying legitimate feelings, even if they’re meant in good fun. Unfortunately this progression from professional banter to inter-service animosity can be seen quite clearly in events this fall in the city of Toronto. With budget cuts looming over emergency services, police, fire and paramedics a like are scrambling to justify their operating costs. This scramble seems to have brought out the worst in all of them, with each service trying to promote themselves at the expensive of the others. We’ve turned on one another; we’ve placed ourselves above our comrades in arms, even going as far as to deny they are our comrades at all. This isn’t the path of progression and this isn’t the path of accountability to the communities that we serve. We owe it not only to ourselves, but those communities, to provide a united front in the face of any adversity. Regardless of whether it’s providing the best medical care for a patient, or facing budget cuts and restructuring during difficult times, it is together, as a united front, that we should face these challenges.

Admittedly, even now, working as a paramedic, I struggle to always remain professional with other pre-hospital services, but it’s the little changes that we each make that cause the big changes to occur. We need to support each other, we need to work together, and we need to ensure that we face any adversity as a united front. If we don’t appreciate that the different responsibilities and skillsets we have all compliment and support each other, then we limit ourselves and deprive our communities of the best patient possible care. I want to finish with a quote from the great scholars Wilbert Harrison, Canned Heat, and George Thorogood & The Destroyers: “together we stand, divided we fall, come on now people let’s get on the ball and work together”. So what does it come down to? You are the cause of the change you want to see, so let’s all work together.

Dan Stein is a Primary Care Paramedic working in Simcoe County. He has been an Emergency Medical Responder for 6 years, and was a member of the Wilfrid Laurier University Emergency Response Team during undergrad. Dan is the current President of the Association of Campus Emergency Response Teams, a national organization that oversees first-aid teams on Canadian campuses.

Hand infections are important to recognize in the emergency setting. Prompt recognition and initiation of treatment are necessary to prevent loss of hand function. In the EMS setting, most infections will be seen in the context of traumatic injury.

Location:
The most common hand infections involve the distal tip of the fingers. These include nail fold infections known as paranechiae and eponechiae and deep pulp infections of the finger tip. These infections are considered relatively minor. However they often require incision and drainage to remove pus and relieve pressure. These infections can also spread to the hand if not recognized and treated.

Distal finger infections may move into the tendonous sheath of the fingers and palm on the palmar side of the hand. This is known as flexor tenosynovitis. This condition is important to recognize as a pre-hospital care provider, as it is a surgical emergency and requires immediate treatment by a plastic surgeon. Patients with flexor tenosynovitis present with globally swollen fingers which are held in a semi-flexed position. Patients will not allow the examiner to extend their fingers straight due to pain. They will also be tender along the affected tendon.

“Fight bite” is a potentially serious infection which may be seen by EMS providers. In this situation, an individual punches another person impacting one of their knuckles on the victim’s teeth. Although this may appear as a simple laceration on the individual’s knuckle, it is important to suspect more serious injury. Due to the location, it is common for teeth to violate the joint capsule or injure the extensor tendon to the finger. Human saliva has especially virulent organisms which spread quickly and destroy tissue when a wound is inoculated. When assessing a patient who may have suffered a fight bite injury, it is important to assess the wound with the patient’s hand held in a fist to look for foreign bodies (i.e. toot fragments) and to irrigate the wound thoroughly in this position. Loose dressings should be applied and the hand should be splinted for comfort.

The hand has a number of potential spaces deep in the palm which may develop collections of pus. Again, the most common mechanism of infection is secondary to trauma. In this situation, the affected area is generally swollen and red and the patient has limited hand function. When comparing the affected hand to the unaffected hand, the examiner will note a loss of the normal concavity of the palm secondary to a collection of pus in the palm.

Animal Bites:
Animal bites are a common cause of hand trauma and infection. By far the most common are from dogs and largely affect children. Cats are also commonly implicated and generally these injuries are worse than those produced by dogs because of the depth that cat teeth pierce. Wild animals are also implicated. Animal saliva contains a variety of virulent organisms which often require prophylactic antibiotics. Additionally, rabies must be considered with animal bites. As an EMS provider, priorities include copious irrigation, loose dressing application, splinting of the hand and a detailed history of the circumstances of the animal bite. Animal control should be involved immediately. If possible, the animal should be captured for assessment as a potential carrier of rabies. If the animal is domesticated, it should be quarantined and observed for any symptoms of rabies.

Necrotizing fasciitis:
Necrotizing fasciitis (aka “flesh eating” disease) is a rapidly progressing, life threatening infection that can affect any area of the body. Prompt recognition by the EMS provider is potentially life-saving. Certain bacteria spread quickly through the planes of a patient’s tissue and progress to systemic illness and cardiovascular collapse. Clinical features that should prompt considering necrotizing fasciitis include rapidly progressing infection over hours, pain out of proportion to the size of the infection, presence of crepitations (crunching) because of gas in the tissues and black, necrotic looking tissue. This represents a patient who should be triaged for immediate treatment in the emergency department. Long off-load delay because of an underestimation of the severity of the infection may be life-threatening.

Infectious source:
An important component of the EMS provider’s assessment of hand infections involves determining the history of infectious exposure. This should include questions about nail biting, exposure to dirt/soil, impaled or embedded objects, fecal contamination or other bacterial exposures. This history can help the emergency physician in selecting an appropriate antibiotic for treatment.

Summary:
Hand infections can be minor and self-limited or potentially life or limb threatening. The pre-hospital care provider should obtain a detailed history to determine potential sources of infection. Additionally, treatment should include copious irrigation as soon as possible with normal saline. Lacerations and lesions should be loosely dressed to allow for continued drainage. Also, hand infections should be splinted and elevated for comfort and to prevent spread of infection during transport to hospital. If EMS providers suspect infections such as flexor tenosynovitis or necrotizing fasciitis, these concerns should be communicated to the triage nurse immediately and should prompt rapid assessment by the emergency physician.

Dr. Morgan Hillier is an emergency medicine resident with the division of Emergency Medicine, faculty of Medicine at the University of Toronto. Dr. Hillier has a research interest in pre-hospital care and holds and EMR Instructor Trainer status with the Canadian Red Cross.

Not Just Golfing in the Sun

When someone says they are going on a business trip, most of us would think that they are going to some wonderful place for round or two of golf and beer. While I don’t contest that this is a part of many meetings, there is much more that goes on behind the scenes. Recently I had the opportunity to attend the American Heart Association’s Resuscitation Science Symposium. This two-day conference was geared specifically towards advancing resuscitation and included everything from working on cells to full blown clinical trials. And let me tell you…it wasn’t just golfing in the sun. So I thought I would share what else goes on at these conferences.

The Networking…

Conferences are a great place to network. Not only are people for the most part friendly, everyone shares a common interest. And it is through networking and collaboration that research advances. It is great if someone has a new analytical approach, but it does nothing for patients (and the research process for that matter) if there is nobody around to implement it. Networking is also a great opportunity to bounce ideas off others. Each person brings a unique perspective to a problem…and a unique solution. Based on their experiences, training and expertise, two people will have totally different approaches to the same problem. Also, as someone just starting out in the field, I found it super helpful to build connections with other research groups whom I might consider working with in the future. And, I have the most to gain from veteran researchers. So far I have had very few opportunities like this, so I would recommend making the most of them.

The Science…

This may seem redundant, as they are scientific conferences, but the meeting is really about the science. Everyone has his or her own area of interest and expertise that they dedicate their time towards. However, ones area is just a sliver in the grand scheme of things. Just to show you, there were over 250 abstracts presented, each unique in its own way. There were abstracts on everything on the resuscitation spectrum. From incidence of cardiac arrests and trauma to bystander CPR to outcomes, from small animal model studies to randomized control trials involving thousands of patients. There was presentations on which drugs or devices are better, or how to best measure performance. And you can’t forget all the product marketing trying you to use their defibrillator or their antirhythmic either. All of which goes to show that there is fascinating work being conducted around the world, which given time will change practice and improve outcomes.

And Then Everything Else…

I would be foolish if I didn’t mention the other part of conferences. While the networking and the science are great…there are other parts that are equally important. Events like these are a great opportunity foster relationships with coworkers, whether strengthen existing ones or build new ones all together. While there is little free time in the schedule, you can always make something work. Either sneak away for an hour or two of bargain shopping or out for a night on the town. Or maybe even a round of golf and beers if the weather is right. Regardless there is always time to take in what the host city has to offer.

Overall scientific conferences can be a great mix between work and play. But it is all up to you what you want to get out of them. If you want to go shop, socialize and golf during the whole conferences that great. But if you want to spend the whole time at the convention center that is fine too. You get out of it what you put in. Personally, I found that mixing the science with a small vacation worked best. I make valuable connections with international researchers and listened to some fascinating presentations…but I also got a little me time and did some of the fun stuff as well. So if you ever get the opportunity to take part in a conference / business meeting etc…go for it!

Jason Buick is a researcher at Rescu, the resuscitation science program at St. Michael’s Hospital and is completing his Masters degree in Health Research at the University of Toronto.  His research interests focus around prehospital care, specifically bystander CPR and out-of-hospital cardiac arrests.

EMSStudent.ca has begun a new initiative and we hope to bring you up to date each month with 3 different articles or article reviews. The material covered will range from diseases and pathophysiology to new studies in the field, and even current events in Ontario communities. The DIGEST will be released on the first day of each month.

Differential Diagnosis

As you get your information from dispatch, you are often only given a small amount of information. As you are on route to your destination, what are some questions you should be ready to ask? What diagnostic tools will you want to use? What tests can you do in the field?

You are called Code 4 to abdo pain and difficulty breathing.

Leave the questions you would ask, in the comment section below, the best ones will be featured in next months digest!