Phencyclidine is a substance that causes hallucinations.  It is commonly known as PCP and is considered an extremely dangerous drug that has been attributed to assaults, murders, and suicides.  In the late 1950’s PCP was developed to be a dissociative anesthetic capable of keeping a patient awake but unresponsive to pain.  The hallucinogenic aspects of this drug caused it to be discontinued from use in humans.  It is still used in veterinary medicine.

PCP is metabolized by the liver.  If large quantities of the drug are taken the liver will process and metabolize the drug forming a high concentration in the urine.  PCP can stay in the system anywhere from half an hour to 4 days depending on the dose.
A person under the influence of PCP will experience three stages of psychological effect.  The first stage will cause the person to feel a change of body image.  The second stage will cause a person to experience distorted hearing and vision.  The third stage occurs when the patient feels alienated, estranged from others and apathetic.

Physically, there are several obvious effects of PCP on the body.  A person under the influence of PCP will be flushed and sweat profusely.  The patient’s eyes will have rapid eye movements and double vision.  The eye lids will also droop.  Most people under the influence of PCP will exhibit signs similar to alcohol intoxication such as staggering and generalized numbness of the extremities.

Many people under the influence of PCP also exhibit signs of paranoid behavior and can be self-destructive.  There are other physiological changes that can manifest, such as trachycardia, hypertension, respiratory depression, muscle rigidity, increased reflexes, and seizures.

There is no treatment or antidote for PCP.  The only treatment that can be done for a person under the influence of PCP is to put the person in a dark room, away from sensory stimulation and unable to self-inflict injury.  There are certain drugs that are often administered to help reduce the effects of anxiety and psychosis.

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When I first got out of school, I took a job in a county psychiatric hospital.  Six months later, I heard of higher-paying job that had opened opened in the ER where I had worked as a student, so I switched jobs.  I was told I’d be starting out with orientation for two weeks, working the night shift, and working with an experienced nurse.

My second night on the job, I came in and discovered that it was the night nurse’s day off and I would be working alone!  I was very nervous, to say the least, but I was assured by the unity clerk that because this was a small community hospital and it didn’t usually see much trauma, weeknights were generally pretty quiet.  Though that should have tipped me off, I instead simply convinced myself I’d survive.   At about 2AM, a man burst through the ER doors shouting, “I’ve been stabbed!”  He ran past me into the treatment room and threw himself onto a stretcher.

When I finally caught up with him, he had sprawled himself facedown on a stretcher, and I could see that his back was a mass of clotted blood.  The unit clerk located the ER physician, and I began to take the patient’s clothes off and take his vital signs.  When the ER doctor came in, we sprang into action getting an intravenous line started and cleaning the wounds to assess the seriousness of the situation.  Suddenly the man began to have difficulty breathing.

The ER doctor ordered that the on-call thoratic chest surgeon be summoned.  This only added to my unease as the surgeon on call that night was a big shot in every sense of the word – a very talented surgeon, but generally unfriendly, intimidating, and a no-nonsense kind of guy.

The surgeon quickly took over and the ER physician stepped out before I could explain I was new on the job and wished he would stay.  The surgeon asked me for the thorocotomy tray and directed me to set up the underwater drainage bottles, wich at that time were used instead of suction to produce negative pressure for the chest tubes.  This was all new to me.  I got out the tray and called the night supervisor to locate the drainage equipment.

When the equipment arrived, the surgeon asked me to set it up.  I had no idea what to do!  Although I was a wreck inside, I very calmly-at least on the surface and said, “I’ve never set one up before.  You’ll have to tell me what to do.”  I’ll never forget the surgeon’s eyes as he looked up at me over the half glasses perched on the end of his nose, relaying a look of “you’re kidding right?”  He proceeded to walk me through the procedure.

Somehow I held it all together and made it through the experience and the night.  Both the patient and I survived, and I learned more that night than I have ever expected I would.

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As first responders to emergency situations, Emergency Medical Technicians (EMT) are trained to be able to identify and treat patients who may be in shock.  This very life-threatening condition requires quick action by the EMT.

Any treatment that is used for shock must be able to increase cardiac output, blood pressure and oxygenation of tissues.  The best way to treat for shock is to treat the cause and also provide supportive measures that can help reduce shock symptoms like:

1.    Have the patient lie flat.
2.    Support the patient’s legs so that the patient’s feet can be raised.
3.    Keep the patient warm by using blankets but be careful not to overheat the patient.
4.    Saturate the patient with oxygen.  This can be accomplished by using a mask attached to an oxygen canister.  Be sure that the patient has an open airway and use an endotracheal tube if necessary.  If the patient is unable to breath independently then artificial ventilation may be necessary.
5.    Administer intravenous fluids or blood if needed.  It is important not to overload the patient’s circulation.
6.    A patient who is in shock because of kidney failure will probably need dialysis until the organs are able to function normally.

Whatever the cause may be, shock symptoms should be treated immediately to prevent serious problems or even death.

Shock can be prevented in patients who are known to have severe allergies.  Many patients with severe allergies have adrenaline self-injection kits that they can use as soon as they are aware of any early symptoms of shock.  Some early signs of shock are difficulty breathing, abdominal cramps, and puffiness.

Patients with bleeding infections or heart attacks should be helped immediately to prevent shock.  Shock can be prevented by providing excellent patient care and the early treatment of severe infections and pain relief when out in the field.

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Emergency medical technicians (EMTs) are usually one of the first responders at a trauma scene. Most often patients involved in traumatic accidents or situations are in shock. More than just being surprised, shock is a life-threatening condition that often occurs in patients who have suffered from severe trauma, infection, allergy or heart attack. Shock causes the body’s circulation to collapse. When the circulation is slowed the pressure in the arteries begins to fall and eventually the tissues and organs of the body are unable to maintain an adequate oxygen supply.

Some common symptoms of shock that an EMT or paramedic might look for  include all or some of the following: -Pale, cold sweaty appearance -Nausea and thirst -Dry mouth -Irregular breathing -Chest pain -Dilated pupils -Loss of consciousness -Reduces urine output -Confusion or agitation -Warm hands and feet -Fast heartbeat -Swelling of the face Shock is commonly caused by a reduction in the volume of blood circulating through the body. Most often this reduction is due to several possible factors like: Internal or external bleeding Dehydration- This can occur if a patient experiences frequent vomiting or diarrhea. Acute pancreatitis, heat exhaustions, diabetic coma and burns can also cause fluid loss and dehydration. Dilated blood vessels- Bacteria can cause septic or toxic shock when the toxins from the bacteria enter the bloodstream. These toxins often cause severe allergic reactions which can cause the peripheral veins to become dilated inevitably reducing circulating blood volume. Damage to the heart muscle- A myocardial infarction can damage the heart making it more difficult for the heart to pump strongly. A weakened heart is unable to circulate blood effective through the body. Loss of heart’s normal rhythm- A heart arrhythmia is a condition that occurs when the heart beats too quickly, too slowly or irregularly. Whenever the heart is not operating in a normal rhythm it becomes less effective at circulating blood. Pulmonary emboloism- A blood clot can occur in a completely different part of the body and directly affect the heart. For example: If a blood clot from the leg finds its way into the lungs tissue it can become lodged and prevent the flow of blood from the right side of the heart to the lungs. Cardiac tamponade- This condition occurs when excess fluid surrounds the heart in the pericardium. The excess fluid causes the heart muscle to become constricted, which prevents normal filling.

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Emergency medical technicians are often called to cases where a patient is experiencing heart problems as serious as heart failure.  Heart failure is a condition that occurs when a person’s heart stops pumping blood to the different parts of the body efficiently.  This can cause tissues and organs to be deficient in oxygen and nutrients.  When an EMT is called to treat a patient who is experience heart failure there are several symptoms that should are associated with heart failure.

Tiredness- Patients who experience severe heart failure are the most likely to feel tired, exhausted or worn out.

Breathless-  Often patients with heart failure feel breathless.  They are typically breathless whenever they must exert themselves.  Eventually the feeling of breathlessness will occur even when the patient is resting.

Coughing up-  A pink or white stained frothy sputum may be coughed up.  The cause of the colored sputum is from congestion in the lungs and fluid retention in the body.

Swelling-  A patient with heart failure may experience swelling in the ankles, lower back and thighs.  Patients who are bedridden will experience the swelling in the thighs and lower back because the fluid can accumulate in those areas very easily.  Patients who are still mobile will likely have swelling in the ankles because of gravity.

Weight loss- Heart failure can cause a patient to lose his or her appetite, feel nausea or vomit frequently.  These symptoms are very common with patients in this condition.

Abdominal pain- Some patients experience abdominal pain.  Doctors have determined that most often abdominal pain that occurs during heart failure is the result of liver congestion.

Most cases of heart failure are caused by the heart being damaged from several possible conditions such as coronary heart disease, chronic heart muscle disorders, hypertension, acute or chronic myocarditis, valvular disease, narrowing of the aorta, high output demand or impeded heart flow.

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As a health-care provider, you will often have patients that are unable to swallow or ingest anything orally.  For patients in this situation, another route for administering medications must be used.  A nasogastric tube or a gastrostomy tube can be used to administer medications into the patient’s stomach.
A nasogastric tube must be passed through the the nose and into the stomach opening in order for medications to be administered directly into the stomach.   This tube can also be used as a feeding tube and to remove any stomach contents when necessary.  The gastrostomy tube is used by inserting the tube through the skin and directly into the stomach.  This tube is used as the primary feeding tube for administering medications.

The following protocol should be used whenever nasogastric or gastrostomy tubes are used to administer medications to patients.
-Always check the prescriber’s order to ensure that you are performing the correct procedure on the right patient and to double check that you are following all of the necessary instructions.
-Ensure that the tube is in the right position by doing either of these methods:
1.    Attach a syringe to the free end of an NG tube.  Then, inject 1 or more 20 mL bursts of air into the tube.  Then aspirate the gastric contents and check the pH of the contents with litmus test paper.  If the paper shows the acidity of the gastric contents to be between 0 and 4 then the tube is correctly positioned in the stomach.
2.    Inject 10 mL of air through an NG tube.  Use a stethoscope over the stomach to listen for a rush of air.  This step is not performed when inserting a gastronomy tube.

-Once the tube is properly positioned, remove the plunger from a syringe and pour the medications to be administered to the patient into the syringe.

-Close the clamp on the nasogastric or gastrostomy tube and attach the syringe.

-Once the syringe is attached open the clamp on the tube and hold the tube up so that the medication in the syringe can flow down the tube and into the patient.

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There are several ways that a medication can be administered to a patient by an EMT or Paramedic.   Certain types of medications require specific routes.  Medications that are injected intradermally have a localized effect on the injection area.  The injected medication does not enter the blood stream.  Instead, the injected medication is meant to pool at the injection site and create a wheal (blister).

Health-care providers that perform intradermal medications should follow specific protocol in order to administer the medication correctly.  Intradermal injections should be given using a 26-27 gauge needle and a 1 mL syringe that is calibrated in 0.01 mL increments.  On average, a typical injection is between 0.01 to 0.1 mL.

To inject medication intradermally the health-care provider should first check the prescriber’s medication order to ensure that the right medication and dosage is being given to the right patient.   Once the medication order is verified, the health-care provider should wash hands and put on a new pair of clean gloves.  Avoid using latex gloves.  The patient should be properly identified before the injection occurs.  The injection site should be cleansed with alcohol or betadine in a circular motion depending on the medication that is being injected or the policy of the health-care facility.  The nurse should hold the patient’s skin taut and position the belvel up while inserting the needle at a 10-to-15-degree angle.  When done correctly, you should be able to see a faint outline of the needle beneath the skin.  The medication can now be injected slowly into the site to form a wheal (blister).  Once the wheal forms, slowly remove the needle.  Do not massage the injection site.  Instead, mark the injection site with a pen so that you will be able to find the site again later.  Give the patient instructions not to wash the mark off until the health-care provider has assessed the site and determined if a reaction has taken place.  The patient should return to have the injection site assessed between 24 and  72 hours after the injection.  If the patient is allergic to the medication that was injected than the diameter of the wheal will increase.

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There are two types of bacteria that can be identified by the color of stain they show in a gram stain test, which is used to identify bacteria.  Gram-positive bacteria will appear purple after staining and gram-negative bacteria will appear pink.  Certain antibiotics are effective against specific bacteria.  Macrolide antibiotics are effective against both types.

Macrolide antibiotics are bacteriostatic antibiotics that are effective against inhibiting the production of bacteria.  These types of antibiotics do not kill bacteria.  Instead they control the bacterial growth.  By controlling bacterial growth the body’s immune system and other medications are given time to kill the bacteria before it can spread.

Most physicians prescribe macrolide antibiotics to fight specific types of infections, such as soft tissue, skin, respiratory and gastrointestinal tract infections.  There are some side effects associated with the use of macrolide antibiotics that include nausea, vomiting, stomach pain, and cramps.  These specific side effects are common with the following types of antibiotics: azithromycin, clarithromycin, erythromycin, dirithromycin and troleandomycin.

As with any other antibiotic, the patient should be assessed for antibiotic allergies before the macrolide antibiotic is administered.  There are certain situations when macrolide antibiotics should be cautiously administered or not administered at all.  Also certain types of macrolide antibiotics may be avoided for patients with certain health problems.  Patients with liver disease should only be given macrolide antibiotics after carefully assessing their condition.  Patients with a history of arrhythmias should not be given erythromycin.

Macrolide antibiotics should be taken with a full glass of water either an hour before or two hours after meals to avoid stomach pain.  For patients who are sensitive or intolerant to macrolide antibiotics, enteric-coated or delayed-release capsules should be prescribed.  Macrolides can also be administered intravenously.

Certain drugs that interact with macrolide antibiotics can have a toxic effect.  The drugs terfenadine or astemizole can cause heart toxicity when given with macrolides.  The risk for hemorrhage also increases with warfarin and macrolides are taken during the same time.

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In 1940, a certain type of mold was discovered to be effective at killing microorganisms. Til today, it is still the most effective antimicrobial drug and is called Penicillin. Most people have been prescribed Penicillin to treat common infections. It is the least toxic of all antimicrobial drugs and is effective at weakening the cell wall of bacteria, eventually causing the cell to rupture and die.

Your doctor will likely prescribe penicillin against gram-positive bacteria. Even some gram-negative bacteria can be destroyed by penicillin. There are certain types of bacteria that contain enzymes that are able to destroy penicillin. In these instances, other types of medications will have to be used.

There are four types of penicillin a physician can use. They are:

1.    Basic:

2.    Penicillinase-resistant

3.    Aminopenicillin

4.    Extended-spectrum

These classifications are based on the drugs ability to kill different types of bacteria. The range of effectiveness is from a narrow to an extremely broad range of effectiveness.

Penicillin is effective at preventing bacterial cells from being able to maintain the integrity of their outer cell wall. Eventually the cell wall ruptures and the cell eventually dies. Depending on the type of penicillin used, the bacteria may either be stopped from proliferating or the bacteria will be killed. For optimal results a patient should always follow the recommended dose and frequency of a prescribed antibiotic medication. Taking less than the prescribed amount can reduce the effectiveness of the drug and have no therapeutic benefit to the body.

There are several precautions that must be taken when penicillin is administered. If it is administered orally it should be given an hour before and after a patient has eaten. Certain types of penicillin, such as amoxicillian, amoxicillin, and clavlanate are not affected by food and can be taken at any time. However, penicillin should be taken with water and not with acidic fruit juices.

Penicillin may also be administered intravenously. In this instance it should be administered slowly due to the large amount of potassium it contains. Too much penicillin at one time can cause heart failure in patients who suffer with renal insufficiency.

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