Guest guest Posted March 13, 2002 Report Share Posted March 13, 2002 Her advice is contrary to all current ATLS protocols, I would certainly like to see her supervisors reaction to these views as well as the companies who are paying for their folks to be trained ( badly). I agree that in someone shut down 18G may initially be all you can put in sometimes not even that, But whenever possible in trauma the largest shortest cannula which gives the largest flow rate should be used..... Nuff said Brash Senior Nurse Supervisor Cabinda Gulf Oil Company e-mail: Amed2@... Telephone: CTN. 8 345 2696 Via London 020 74878100 Cabinda Ext. 2696 > Cannulation and shock > > Hi Folks, > Just thought you might find this interesting. I was at MRI at > Stonehaven on Monday for a day ( unofficial chat about things in general ) > and one of their nurses that trains the medical Aiders on board the rescue > vessels seems to have a different view on cannulation in trauma. At > present all rescue vessels carry sets of cannulas of the usual sizes - 14 > , 16 , 18. > Tthe training that I have in trauma ( having just done my trauma > management refresher ) states that in shock for adult volume replacement > you use 14 / 16 gauge in order to get a rapid flow rate. 18G being used > for drug admin etc. This nurse is now telling me that she advocates the > use of the 18g cannula alone, even in serious trauma , and that we should > take off the other two sizes of cannula. She does not like the large size > of cannula, saying that it is ' barbaric'. As far as I am aware she does > not have any formal pre-hospital quals and was hospital based for most of > her career. > I checked all my stuff and the JRCALC rules and they all say for rapid > fluid admin use 14 / 16 g. > I also met this lady on tuesday at an OPITO meeting where she tried to > get the 14 / 16 g cannulas removed from the equipment lists. This move was > blocked. I would be interested in your views on this. > Regards to all, > Andy > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 13, 2002 Report Share Posted March 13, 2002 Sounds like an unfounded pet theory thing she has going, It would surely be a lot more " barbaric " to have a hypovolaemic patient expire on you due to inadequate fluid replacment. Cheers Stuart >From: " Brash, \\ Lines, Gavin (amed2) " <amed2@...> >Reply- > " ' ' " >< > >Subject: RE: Cannulation and shock >Date: Wed, 13 Mar 2002 02:41:32 -0600 > >Her advice is contrary to all current ATLS protocols, I would certainly >like >to see her supervisors reaction to these views as well as the companies who >are paying for their folks to be trained ( badly). I agree that in someone >shut down 18G may initially be all you can put in sometimes not even that, >But whenever possible in trauma the largest shortest cannula which gives >the >largest flow rate should be used..... > >Nuff said > > Brash >Senior Nurse Supervisor >Cabinda Gulf Oil Company >e-mail: Amed2@... >Telephone: CTN. 8 345 2696 >Via London 020 74878100 Cabinda Ext. 2696 > > > Cannulation and shock > > > > Hi Folks, > > Just thought you might find this interesting. I was at MRI >at > > Stonehaven on Monday for a day ( unofficial chat about things in general >) > > and one of their nurses that trains the medical Aiders on board the >rescue > > vessels seems to have a different view on cannulation in trauma. At > > present all rescue vessels carry sets of cannulas of the usual sizes - >14 > > , 16 , 18. > > Tthe training that I have in trauma ( having just done my trauma > > management refresher ) states that in shock for adult volume replacement > > you use 14 / 16 gauge in order to get a rapid flow rate. 18G being used > > for drug admin etc. This nurse is now telling me that she advocates the > > use of the 18g cannula alone, even in serious trauma , and that we >should > > take off the other two sizes of cannula. She does not like the large >size > > of cannula, saying that it is ' barbaric'. As far as I am aware she does > > not have any formal pre-hospital quals and was hospital based for most >of > > her career. > > I checked all my stuff and the JRCALC rules and they all say for rapid > > fluid admin use 14 / 16 g. > > I also met this lady on tuesday at an OPITO meeting where she tried to > > get the 14 / 16 g cannulas removed from the equipment lists. This move >was > > blocked. I would be interested in your views on this. > > Regards to all, > > Andy > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 13, 2002 Report Share Posted March 13, 2002 Andy, I agree with wholeheartedly about the use of larger bore cannulae, indeed the only occasion I have had to use an 18 in the field for fluid resus was as is said because it was near impossible to get anything else in indeed to get that in some saline had to be used to enhance the vein. I believe that I know the lady in question that you refer to, (I live just down the road from Stoney)and this has been one of her bug bites for a while. I'm afraid that her point about it being " barbaric " is nonsense, lets face it, if they are so bad to require massive fluid replacement or following serious trauma in the field or wherever, do you think the casualty really cares if the needle that goes in is going to hurt a little...................Naa don't think so, they just want the best chance posssible of life. I think probably her opinion comes out of lack of pre hospital experience and a touch of in hospital naiveity As you say it goes against all the studies and guidelines. Regards Nick Farrell FSU SOORENA Persian Gulf Cannulation and shock Hi Folks, Just thought you might find this interesting. I was at MRI at Stonehaven on Monday for a day ( unofficial chat about things in general ) and one of their nurses that trains the medical Aiders on board the rescue vessels seems to have a different view on cannulation in trauma. At present all rescue vessels carry sets of cannulas of the usual sizes - 14 , 16 , 18. Tthe training that I have in trauma ( having just done my trauma management refresher ) states that in shock for adult volume replacement you use 14 / 16 gauge in order to get a rapid flow rate. 18G being used for drug admin etc. This nurse is now telling me that she advocates the use of the 18g cannula alone, even in serious trauma , and that we should take off the other two sizes of cannula. She does not like the large size of cannula, saying that it is ' barbaric'. As far as I am aware she does not have any formal pre-hospital quals and was hospital based for most of her career. I checked all my stuff and the JRCALC rules and they all say for rapid fluid admin use 14 / 16 g. I also met this lady on tuesday at an OPITO meeting where she tried to get the 14 / 16 g cannulas removed from the equipment lists. This move was blocked. I would be interested in your views on this. Regards to all, Andy Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 13, 2002 Report Share Posted March 13, 2002 I would be interested what else she is advocating.... I bet theres a rake of misinformation. bet shes still using EUSOL. cheers Steve Stu, good to see your about, I belive you volunteed me for Tig! >From: " stuart hamer " <hamerstuart@...> >Reply- > >Subject: RE: Cannulation and shock >Date: Wed, 13 Mar 2002 09:28:26 +0000 > >Sounds like an unfounded pet theory thing she has going, It would surely be >a lot more " barbaric " to have a hypovolaemic patient expire on you due to >inadequate fluid replacment. > >Cheers > >Stuart > > > >From: " Brash, \\ Lines, Gavin (amed2) " <amed2@...> > >Reply- > > " ' ' " > >< > > >Subject: RE: Cannulation and shock > >Date: Wed, 13 Mar 2002 02:41:32 -0600 > > > >Her advice is contrary to all current ATLS protocols, I would certainly > >like > >to see her supervisors reaction to these views as well as the companies >who > >are paying for their folks to be trained ( badly). I agree that in >someone > >shut down 18G may initially be all you can put in sometimes not even >that, > >But whenever possible in trauma the largest shortest cannula which gives > >the > >largest flow rate should be used..... > > > >Nuff said > > > > Brash > >Senior Nurse Supervisor > >Cabinda Gulf Oil Company > >e-mail: Amed2@... > >Telephone: CTN. 8 345 2696 > >Via London 020 74878100 Cabinda Ext. 2696 > > > > > Cannulation and shock > > > > > > Hi Folks, > > > Just thought you might find this interesting. I was at >MRI > >at > > > Stonehaven on Monday for a day ( unofficial chat about things in >general > >) > > > and one of their nurses that trains the medical Aiders on board the > >rescue > > > vessels seems to have a different view on cannulation in trauma. At > > > present all rescue vessels carry sets of cannulas of the usual sizes - > >14 > > > , 16 , 18. > > > Tthe training that I have in trauma ( having just done my trauma > > > management refresher ) states that in shock for adult volume >replacement > > > you use 14 / 16 gauge in order to get a rapid flow rate. 18G being >used > > > for drug admin etc. This nurse is now telling me that she advocates >the > > > use of the 18g cannula alone, even in serious trauma , and that we > >should > > > take off the other two sizes of cannula. She does not like the large > >size > > > of cannula, saying that it is ' barbaric'. As far as I am aware she >does > > > not have any formal pre-hospital quals and was hospital based for most > >of > > > her career. > > > I checked all my stuff and the JRCALC rules and they all say for >rapid > > > fluid admin use 14 / 16 g. > > > I also met this lady on tuesday at an OPITO meeting where she tried >to > > > get the 14 / 16 g cannulas removed from the equipment lists. This move > >was > > > blocked. I would be interested in your views on this. > > > Regards to all, > > > Andy > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 13, 2002 Report Share Posted March 13, 2002 Well Said Tony..... Perhaps we should forward all these e mails to her, She may then get some sense in to her Brash Senior Nurse Supervisor Cabinda Gulf Oil Company e-mail: Amed2@... Telephone: CTN. 8 345 2696 Via London 020 74878100 Cabinda Ext. 2696 > Re: Cannulation and shock > > Andy > Let me introduce my self, my name is Tony Twentyman you can see were I > work from > the address block below. I spent 14 years in the Army and then 10 years > in the > RN serving on submarines (you carnt get more remote than that!) I finished > my > time off with a small airborn team specialising in search and rescue > primeraly > with sumbarine escape. I totaly agree with you, but you must face facts > that > some of the rules are manipulated to siut some of the uneducated and to > accomatade lack of skill. We all know it is far easier to insert an 18 g > cannula > but is totaly US in administering large volume fluids. Inform her that > I will > be sticking to 14 and 16 g and to top it off I'll site two, hows that for > barbaric. > > Best Regards > > > Tony > Medic > MV Ramform Viking > > Telephone: Hospital +47 67514833 > Bridge +47 67514810 > > Fax +47 67514850 > > Personal email Bump@... > > ************************************************************************** > ****** > This e-mail transmission is strictly confidential and intended solely for > the > organisation or person to whom it is addressed. It may contain privileged > and > confidential information and if you are not the intended recipient, you > must not > copy, distribute or take any action in reliance on it. > ************************************************************************** > ****** > > > > Member Information: > > List owner: Ian Sharpe Owner@... > Editor: Ross Boardman Editor@... > > Post message: egroups > Subscribe: -subscribeegroups > Unsubscribe: -unsubscribeegroups > > Thank you for supporting Remote Medics Online. > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 13, 2002 Report Share Posted March 13, 2002 Certainly in our neck of the woods one tends to find that the Paramedics are better skilled at large bore IV insertion than the hospital staff. As you say, with little or no formal pre-hospital care training her opinion is probably an uninformed one..... Steve South Africa On Wed, 13 Mar 2002 08:23:30 -0000 andrew.rice (andrew.rice@...) wrote: 155 Forest Drive Pinelands 7405 South Africa Telephone: + 27 21 531 0766 Fax: + 27 21 531 0766 (on request) Mobile: + 27 83 650 7028 Mobile fax: + 27 83 8 650 7028 E-Mail: rhinomed2@... Alternate E-Mail: rhinomed2@... _______________________________________________________________ http://www.webmail.co.za the South-African free email service Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 13, 2002 Report Share Posted March 13, 2002 This lady has never had to deal with a cas with 95% burns a few minutes after the incident where cut downs and wide bore where the only options open so the man got to see his family at least. I don't know about the rest of you but in my 30 years in the game I can think of only a couple of times I've had to set a drip up for therapeutic treatment, 99% of the time is Shit get in fast and stabilize. Barbaric maybe but life saving yes give me full bore any time lol gold wing " Brash, \ Lines, Gavin (amed2) " <amed2@...> wrote: Well Said Tony..... Perhaps we should forward all these e mails to her, She may then get some sense in to her Brash Senior Nurse Supervisor Cabinda Gulf Oil Company e-mail: Amed2@... Telephone: CTN. 8 345 2696 Via London 020 74878100 Cabinda Ext. 2696 > Re: Cannulation and shock > > Andy > Let me introduce my self, my name is Tony Twentyman you can see were I > work from > the address block below. I spent 14 years in the Army and then 10 years > in the > RN serving on submarines (you carnt get more remote than that!) I finished > my > time off with a small airborn team specialising in search and rescue > primeraly > with sumbarine escape. I totaly agree with you, but you must face facts > that > some of the rules are manipulated to siut some of the uneducated and to > accomatade lack of skill. We all know it is far easier to insert an 18 g > cannula > but is totaly US in administering large volume fluids. Inform her that > I will > be sticking to 14 and 16 g and to top it off I'll site two, hows that for > barbaric. > > Best Regards > > > Tony > Medic > MV Ramform Viking > > Telephone: Hospital +47 67514833 > Bridge +47 67514810 > > Fax +47 67514850 > > Personal email Bump@... > > ************************************************************************** > ****** > This e-mail transmission is strictly confidential and intended solely for > the > organisation or person to whom it is addressed. It may contain privileged > and > confidential information and if you are not the intended recipient, you > must not > copy, distribute or take any action in reliance on it. > ************************************************************************** > ****** > > > > Member Information: > > List owner: Ian Sharpe Owner@... > Editor: Ross Boardman Editor@... > > Post message: egroups > Subscribe: -subscribeegroups > Unsubscribe: -unsubscribeegroups > > Thank you for supporting Remote Medics Online. > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 13, 2002 Report Share Posted March 13, 2002 Hi All, I to have encountered the same thoughts here in the states from nursing staff whom are almost always lacking in any pre-hospital care experience and or training. Granted Sticking a 14 gauge in a patient is not something you do for fun and from personal experience it is painful but if you need fluid you need it fast and simple math/hydraulics (spelling?) proves that a 14 gauge is better than a 18 gauge. But in The nurses defence they are not pre hospital providers and they don't know any better. I have not encounter that thought process in Flight nurses etc though. It seems to me its just a failure of thier training. It just adds ammo to my long standing belief that pre-hospital care providers should be taught by people whom are pre-hospital providers not by people whom don't do our job and in some cases never would do or haqve done our job. Just my thoughts take them for what they are worth Cheers Tom G >From: " andrew.rice " <andrew.rice@...> >Reply- >< > >Subject: Cannulation and shock >Date: Wed, 13 Mar 2002 08:23:30 -0000 > >Hi Folks, > Just thought you might find this interesting. I was at MRI at >Stonehaven on Monday for a day ( unofficial chat about things in general ) >and one of their nurses that trains the medical Aiders on board the rescue >vessels seems to have a different view on cannulation in trauma. At present >all rescue vessels carry sets of cannulas of the usual sizes - 14 , 16 , >18. > Tthe training that I have in trauma ( having just done my trauma >management refresher ) states that in shock for adult volume replacement >you use 14 / 16 gauge in order to get a rapid flow rate. 18G being used for >drug admin etc. This nurse is now telling me that she advocates the use of >the 18g cannula alone, even in serious trauma , and that we should take >off the other two sizes of cannula. She does not like the large size of >cannula, saying that it is ' barbaric'. As far as I am aware she does not >have any formal pre-hospital quals and was hospital based for most of her >career. > I checked all my stuff and the JRCALC rules and they all say for rapid >fluid admin use 14 / 16 g. > I also met this lady on tuesday at an OPITO meeting where she tried to >get the 14 / 16 g cannulas removed from the equipment lists. This move was >blocked. I would be interested in your views on this. > Regards to all, > Andy > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2002 Report Share Posted March 14, 2002 Bearing in mind latest evidence on high volume fluid resuscitation, there's a whole other discussion going on at present re, permissible hypovolaemia, and low volume fluids in trauma. Rgs Ian Cannulation and shock > > Hi Folks, > Just thought you might find this interesting. I was at MRI at > Stonehaven on Monday for a day ( unofficial chat about things in general ) > and one of their nurses that trains the medical Aiders on board the rescue > vessels seems to have a different view on cannulation in trauma. At > present all rescue vessels carry sets of cannulas of the usual sizes - 14 > , 16 , 18. > Tthe training that I have in trauma ( having just done my trauma > management refresher ) states that in shock for adult volume replacement > you use 14 / 16 gauge in order to get a rapid flow rate. 18G being used > for drug admin etc. This nurse is now telling me that she advocates the > use of the 18g cannula alone, even in serious trauma , and that we should > take off the other two sizes of cannula. She does not like the large size > of cannula, saying that it is ' barbaric'. As far as I am aware she does > not have any formal pre-hospital quals and was hospital based for most of > her career. > I checked all my stuff and the JRCALC rules and they all say for rapid > fluid admin use 14 / 16 g. > I also met this lady on tuesday at an OPITO meeting where she tried to > get the 14 / 16 g cannulas removed from the equipment lists. This move was > blocked. I would be interested in your views on this. > Regards to all, > Andy > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2002 Report Share Posted March 14, 2002 The American Heart Association actually states that moderate hypothermis is permittable (read you are allowed to let happen, rather than make happen), in treating PEA and Asystole. I'll get more info on it. . Ian Sharpe <Ian@...> wrote: Bearing in mind latest evidence on high volume fluid resuscitation, there's a whole other discussion going on at present re, permissible hypovolaemia, and low volume fluids in trauma. Rgs Ian Cannulation and shock > > Hi Folks, > Just thought you might find this interesting. I was at MRI at > Stonehaven on Monday for a day ( unofficial chat about things in general ) > and one of their nurses that trains the medical Aiders on board the rescue > vessels seems to have a different view on cannulation in trauma. At > present all rescue vessels carry sets of cannulas of the usual sizes - 14 > , 16 , 18. > Tthe training that I have in trauma ( having just done my trauma > management refresher ) states that in shock for adult volume replacement > you use 14 / 16 gauge in order to get a rapid flow rate. 18G being used > for drug admin etc. This nurse is now telling me that she advocates the > use of the 18g cannula alone, even in serious trauma , and that we should > take off the other two sizes of cannula. She does not like the large size > of cannula, saying that it is ' barbaric'. As far as I am aware she does > not have any formal pre-hospital quals and was hospital based for most of > her career. > I checked all my stuff and the JRCALC rules and they all say for rapid > fluid admin use 14 / 16 g. > I also met this lady on tuesday at an OPITO meeting where she tried to > get the 14 / 16 g cannulas removed from the equipment lists. This move was > blocked. I would be interested in your views on this. > Regards to all, > Andy > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2002 Report Share Posted March 14, 2002 Ian, I assume your talking about Hypotensive resuscitation??. I think the Jury is still out on this one, Current thoughts are if you can get them up to a palpable radial pulse ( + / - 90mm hg) then that is perhaps adequate, I would think that perhaps burns may differ a little from trauma as there is plug hole open to force fluids out. It's a tough one one the experts still cannot agree which way to go.... Brash Senior Nurse Supervisor International SOS \ Cabinda Gulf Oil Company e-mail: Amed2@... Telephone: CTN. 8 345 2696 Via London 020 74878100 Cabinda Ext. 2696 > Cannulation and shock > > > > Hi Folks, > > Just thought you might find this interesting. I was at MRI > at > > Stonehaven on Monday for a day ( unofficial chat about things in general > ) > > and one of their nurses that trains the medical Aiders on board the > rescue > > vessels seems to have a different view on cannulation in trauma. At > > present all rescue vessels carry sets of cannulas of the usual sizes - > 14 > > , 16 , 18. > > Tthe training that I have in trauma ( having just done my trauma > > management refresher ) states that in shock for adult volume replacement > > you use 14 / 16 gauge in order to get a rapid flow rate. 18G being used > > for drug admin etc. This nurse is now telling me that she advocates the > > use of the 18g cannula alone, even in serious trauma , and that we > should > > take off the other two sizes of cannula. She does not like the large > size > > of cannula, saying that it is ' barbaric'. As far as I am aware she does > > not have any formal pre-hospital quals and was hospital based for most > of > > her career. > > I checked all my stuff and the JRCALC rules and they all say for rapid > > fluid admin use 14 / 16 g. > > I also met this lady on tuesday at an OPITO meeting where she tried to > > get the 14 / 16 g cannulas removed from the equipment lists. This move > was > > blocked. I would be interested in your views on this. > > Regards to all, > > Andy > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2002 Report Share Posted March 14, 2002 Hi Me again, Just to let you know after a recent chat with a friend! current SF medic's guidelines advocate the use of 18g cannula for controlled hypotension in the field environment, that is the remote area where fluids are at a minimum. let me know if anyone else knows of these guidelines? Toni >From: " Brash, \\ Lines, Gavin (amed2) " <amed2@...> >Reply- > " ' ' " >< > >Subject: RE: Cannulation and shock >Date: Thu, 14 Mar 2002 07:11:00 -0600 > >Ian, > >I assume your talking about Hypotensive resuscitation??. I think the Jury >is >still out on this one, Current thoughts are if you can get them up to a >palpable radial pulse ( + / - 90mm hg) then that is perhaps adequate, I >would think that perhaps burns may differ a little from trauma as there is >plug hole open to force fluids out. > >It's a tough one one the experts still cannot agree which way to go.... > > > > Brash >Senior Nurse Supervisor >International SOS \ Cabinda Gulf Oil Company >e-mail: Amed2@... >Telephone: CTN. 8 345 2696 >Via London 020 74878100 Cabinda Ext. 2696 > > > Cannulation and shock > > > > > > Hi Folks, > > > Just thought you might find this interesting. I was at >MRI > > at > > > Stonehaven on Monday for a day ( unofficial chat about things in >general > > ) > > > and one of their nurses that trains the medical Aiders on board the > > rescue > > > vessels seems to have a different view on cannulation in trauma. At > > > present all rescue vessels carry sets of cannulas of the usual sizes - > > 14 > > > , 16 , 18. > > > Tthe training that I have in trauma ( having just done my trauma > > > management refresher ) states that in shock for adult volume >replacement > > > you use 14 / 16 gauge in order to get a rapid flow rate. 18G being >used > > > for drug admin etc. This nurse is now telling me that she advocates >the > > > use of the 18g cannula alone, even in serious trauma , and that we > > should > > > take off the other two sizes of cannula. She does not like the large > > size > > > of cannula, saying that it is ' barbaric'. As far as I am aware she >does > > > not have any formal pre-hospital quals and was hospital based for most > > of > > > her career. > > > I checked all my stuff and the JRCALC rules and they all say for >rapid > > > fluid admin use 14 / 16 g. > > > I also met this lady on tuesday at an OPITO meeting where she tried >to > > > get the 14 / 16 g cannulas removed from the equipment lists. This move > > was > > > blocked. I would be interested in your views on this. > > > Regards to all, > > > Andy > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2002 Report Share Posted March 14, 2002 Maybe this lady should be given the chance to produce the evidence base to support her teaching. She may or may not have said it, but as the list at the moment is undecided as to what to do once you have the large bore needle in, maybe she should have the chance to explain and produce evidence for the argument. Protocols are great but from the chat so far you obviously have none or they are interpreted differently. Everybody is agreed you must put in large needles but then the list has said 1. put lots of fluid in. 2. put big needles in and then control their hypotension. 3. put big needles in and then just enough to get a radial pulse. 4. put in big needles and then titrate to the bp. The only protocol I can see that she has broken is the one that says you must put in big needles (If of course you can) If the problem is the bleed can not be stopped how does the list propose to stop the bleed without access to a surgeon so they can resuscitate? What size of needle do I put in if it is trauma but that trauma is a closed head injury in isolation with a rising ICP and once it is in what do I do with it? Not trying to stir the mire, I just thought you may be able to tell me from the protocols you all have and hold in high esteem and never diviate from!!! >From: " steve benbow " <sbenbow@...> >Reply- > >Subject: RE: Cannulation and shock >Date: Wed, 13 Mar 2002 09:38:41 +0000 > >I would be interested what else she is advocating.... I bet theres a rake >of >misinformation. bet shes still using EUSOL. > >cheers Steve > >Stu, good to see your about, I belive you volunteed me for Tig! > > > >From: " stuart hamer " <hamerstuart@...> > >Reply- > > > >Subject: RE: Cannulation and shock > >Date: Wed, 13 Mar 2002 09:28:26 +0000 > > > >Sounds like an unfounded pet theory thing she has going, It would surely >be > >a lot more " barbaric " to have a hypovolaemic patient expire on you due to > >inadequate fluid replacment. > > > >Cheers > > > >Stuart > > > > > > >From: " Brash, \\ Lines, Gavin (amed2) " <amed2@...> > > >Reply- > > > " ' ' " > > >< > > > >Subject: RE: Cannulation and shock > > >Date: Wed, 13 Mar 2002 02:41:32 -0600 > > > > > >Her advice is contrary to all current ATLS protocols, I would certainly > > >like > > >to see her supervisors reaction to these views as well as the companies > >who > > >are paying for their folks to be trained ( badly). I agree that in > >someone > > >shut down 18G may initially be all you can put in sometimes not even > >that, > > >But whenever possible in trauma the largest shortest cannula which >gives > > >the > > >largest flow rate should be used..... > > > > > >Nuff said > > > > > > Brash > > >Senior Nurse Supervisor > > >Cabinda Gulf Oil Company > > >e-mail: Amed2@... > > >Telephone: CTN. 8 345 2696 > > >Via London 020 74878100 Cabinda Ext. 2696 > > > > > > > Cannulation and shock > > > > > > > > Hi Folks, > > > > Just thought you might find this interesting. I was at > >MRI > > >at > > > > Stonehaven on Monday for a day ( unofficial chat about things in > >general > > >) > > > > and one of their nurses that trains the medical Aiders on board the > > >rescue > > > > vessels seems to have a different view on cannulation in trauma. At > > > > present all rescue vessels carry sets of cannulas of the usual sizes >- > > >14 > > > > , 16 , 18. > > > > Tthe training that I have in trauma ( having just done my trauma > > > > management refresher ) states that in shock for adult volume > >replacement > > > > you use 14 / 16 gauge in order to get a rapid flow rate. 18G being > >used > > > > for drug admin etc. This nurse is now telling me that she advocates > >the > > > > use of the 18g cannula alone, even in serious trauma , and that we > > >should > > > > take off the other two sizes of cannula. She does not like the large > > >size > > > > of cannula, saying that it is ' barbaric'. As far as I am aware she > >does > > > > not have any formal pre-hospital quals and was hospital based for >most > > >of > > > > her career. > > > > I checked all my stuff and the JRCALC rules and they all say for > >rapid > > > > fluid admin use 14 / 16 g. > > > > I also met this lady on tuesday at an OPITO meeting where she >tried > >to > > > > get the 14 / 16 g cannulas removed from the equipment lists. This >move > > >was > > > > blocked. I would be interested in your views on this. > > > > Regards to all, > > > > Andy > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2002 Report Share Posted March 14, 2002 Gordon, Protocols are in place as guidelines, Surely it is safer to put in a 14 - 16 gauge cannula " Just in case " rather than a small one and then find yourself in trouble. Even with controlled Hypotension 14 - 16 g is still advocated. Hell I think the lady should be allowed to say her piece, And if her teachings are evidence based than... Good for her, however I can't imagine any traumatologist telling us to use an 18 or 20 gauge cos it's much kinder !! . Brash Senior Nurse Supervisor International SOS \ Cabinda Gulf Oil Company e-mail: Amed2@... Telephone: CTN. 8 345 2696 Via London 020 74878100 Cabinda Ext. 2696 > Cannulation and shock > > > > > > > > > > Hi Folks, > > > > > Just thought you might find this interesting. I was > at > > >MRI > > > >at > > > > > Stonehaven on Monday for a day ( unofficial chat about things in > > >general > > > >) > > > > > and one of their nurses that trains the medical Aiders on board > the > > > >rescue > > > > > vessels seems to have a different view on cannulation in trauma. > At > > > > > present all rescue vessels carry sets of cannulas of the usual > sizes > >- > > > >14 > > > > > , 16 , 18. > > > > > Tthe training that I have in trauma ( having just done my trauma > > > > > management refresher ) states that in shock for adult volume > > >replacement > > > > > you use 14 / 16 gauge in order to get a rapid flow rate. 18G being > > >used > > > > > for drug admin etc. This nurse is now telling me that she > advocates > > >the > > > > > use of the 18g cannula alone, even in serious trauma , and that > we > > > >should > > > > > take off the other two sizes of cannula. She does not like the > large > > > >size > > > > > of cannula, saying that it is ' barbaric'. As far as I am aware > she > > >does > > > > > not have any formal pre-hospital quals and was hospital based for > >most > > > >of > > > > > her career. > > > > > I checked all my stuff and the JRCALC rules and they all say for > > >rapid > > > > > fluid admin use 14 / 16 g. > > > > > I also met this lady on tuesday at an OPITO meeting where she > >tried > > >to > > > > > get the 14 / 16 g cannulas removed from the equipment lists. This > >move > > > >was > > > > > blocked. I would be interested in your views on this. > > > > > Regards to all, > > > > > Andy > > > > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2002 Report Share Posted March 14, 2002 Fluid replacement in burns is different, fluid loss in burns is as I'm sure you all know is not usually early. However, a 20% 2nd degree burn will cause the fluid shift from interstitial fluid to bolster the circulating fluid ~ usually in a period of hours. There are a number of fluid replacement formulas out there, we opted for the Parkland, 4mls x tbsab x kg over the first 8 hrs and same volume over the next 16 hrs ~ during this time group and xmatch & O neg may be required. Hopefully I will have landed the pt during this time. Ian H Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2002 Report Share Posted March 14, 2002 Anyone that has been through Keogh in the last couple of years will have been taught this. Ian H Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2002 Report Share Posted March 14, 2002 Raised icp will need CVS support eventually. You may have to support the BP at a higher ~ 100~120mmHg to maintain circulation to the brain. I use big needles, but am careful with the fluid challenge, if you only use a small needle and you need to scoot the fluid along then your stuffed, larger needles give you both options. Ian H Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2002 Report Share Posted March 14, 2002 We still quote that on our acute care courses, mainly avcat for us mallots though. Ian H Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2002 Report Share Posted March 14, 2002 SF as in Special forces? Their guidlines say no such thing mate, been there done that, full on big bore all the way. I don't know of any shortage of fluids for those boys! They have no chance to do a full on check for hypotension and control. Just open wide and run like F@#K. Sort out later. .MM and generally dead 'ard bastard. Toni Murch <tonimedic@...> wrote: Hi Me again, Just to let you know after a recent chat with a friend! current SF medic's guidelines advocate the use of 18g cannula for controlled hypotension in the field environment, that is the remote area where fluids are at a minimum. let me know if anyone else knows of these guidelines? Toni >From: " Brash, \\ Lines, Gavin (amed2) " <amed2@...> >Reply- > " ' ' " >< > >Subject: RE: Cannulation and shock >Date: Thu, 14 Mar 2002 07:11:00 -0600 > >Ian, > >I assume your talking about Hypotensive resuscitation??. I think the Jury >is >still out on this one, Current thoughts are if you can get them up to a >palpable radial pulse ( + / - 90mm hg) then that is perhaps adequate, I >would think that perhaps burns may differ a little from trauma as there is >plug hole open to force fluids out. > >It's a tough one one the experts still cannot agree which way to go.... > > > > Brash >Senior Nurse Supervisor >International SOS \ Cabinda Gulf Oil Company >e-mail: Amed2@... >Telephone: CTN. 8 345 2696 >Via London 020 74878100 Cabinda Ext. 2696 > > > Cannulation and shock > > > > > > Hi Folks, > > > Just thought you might find this interesting. I was at >MRI > > at > > > Stonehaven on Monday for a day ( unofficial chat about things in >general > > ) > > > and one of their nurses that trains the medical Aiders on board the > > rescue > > > vessels seems to have a different view on cannulation in trauma. At > > > present all rescue vessels carry sets of cannulas of the usual sizes - > > 14 > > > , 16 , 18. > > > Tthe training that I have in trauma ( having just done my trauma > > > management refresher ) states that in shock for adult volume >replacement > > > you use 14 / 16 gauge in order to get a rapid flow rate. 18G being >used > > > for drug admin etc. This nurse is now telling me that she advocates >the > > > use of the 18g cannula alone, even in serious trauma , and that we > > should > > > take off the other two sizes of cannula. She does not like the large > > size > > > of cannula, saying that it is ' barbaric'. As far as I am aware she >does > > > not have any formal pre-hospital quals and was hospital based for most > > of > > > her career. > > > I checked all my stuff and the JRCALC rules and they all say for >rapid > > > fluid admin use 14 / 16 g. > > > I also met this lady on tuesday at an OPITO meeting where she tried >to > > > get the 14 / 16 g cannulas removed from the equipment lists. This move > > was > > > blocked. I would be interested in your views on this. > > > Regards to all, > > > Andy > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2002 Report Share Posted March 14, 2002 I agree the argument that an 18g is kinder is a pretty poor argument but, I have heard so many people say things and then they have been miss quoted. It is fair, as you say, to let her have her say; produce an evidence base and then judge. I think there are so many ways to replace fluid and so many different types of fluid that you can only argue for one against the other dependant on the casualty, location, operator skill and circumstance. The large and thick does the trick arguement of the traumatologist holds water for them as they have access to blood and surgery. Remote medics do not always have such luxuries. I have heard some one say the best pre-hospital fluid is diesel or petrol. >From: " Brash, \\ Lines, Gavin (amed2) " <amed2@...> >Reply- > " ' ' " >< > >Subject: RE: Cannulation and shock >Date: Thu, 14 Mar 2002 07:47:48 -0800 > >Gordon, > >Protocols are in place as guidelines, Surely it is safer to put in a 14 - >16 >gauge cannula " Just in case " rather than a small one and then find >yourself in trouble. Even with controlled Hypotension 14 - 16 g is still >advocated. > >Hell I think the lady should be allowed to say her piece, And if her >teachings are evidence based than... Good for her, however I can't imagine >any traumatologist telling us to use an 18 or 20 gauge cos it's much kinder >!! > >. > > Brash >Senior Nurse Supervisor >International SOS \ Cabinda Gulf Oil Company >e-mail: Amed2@... >Telephone: CTN. 8 345 2696 >Via London 020 74878100 Cabinda Ext. 2696 > > > Cannulation and shock > > > > > > > > > > > > Hi Folks, > > > > > > Just thought you might find this interesting. I was > > at > > > >MRI > > > > >at > > > > > > Stonehaven on Monday for a day ( unofficial chat about things in > > > >general > > > > >) > > > > > > and one of their nurses that trains the medical Aiders on board > > the > > > > >rescue > > > > > > vessels seems to have a different view on cannulation in trauma. > > At > > > > > > present all rescue vessels carry sets of cannulas of the usual > > sizes > > >- > > > > >14 > > > > > > , 16 , 18. > > > > > > Tthe training that I have in trauma ( having just done my >trauma > > > > > > management refresher ) states that in shock for adult volume > > > >replacement > > > > > > you use 14 / 16 gauge in order to get a rapid flow rate. 18G >being > > > >used > > > > > > for drug admin etc. This nurse is now telling me that she > > advocates > > > >the > > > > > > use of the 18g cannula alone, even in serious trauma , and that > > we > > > > >should > > > > > > take off the other two sizes of cannula. She does not like the > > large > > > > >size > > > > > > of cannula, saying that it is ' barbaric'. As far as I am aware > > she > > > >does > > > > > > not have any formal pre-hospital quals and was hospital based >for > > >most > > > > >of > > > > > > her career. > > > > > > I checked all my stuff and the JRCALC rules and they all say >for > > > >rapid > > > > > > fluid admin use 14 / 16 g. > > > > > > I also met this lady on tuesday at an OPITO meeting where she > > >tried > > > >to > > > > > > get the 14 / 16 g cannulas removed from the equipment lists. >This > > >move > > > > >was > > > > > > blocked. I would be interested in your views on this. > > > > > > Regards to all, > > > > > > Andy > > > > > > > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2002 Report Share Posted March 14, 2002 Gordon, have a read back through what's been said and you see that most of what has been said relates to possible future new recommendations, not what we have on protocols. Now if you don't know protocols, where they are and what they are, pray tell, what are you doing in this job? As for the lady concerened, it's upto the person who was there and feels that there is a complaint to answer, that needs to complain to the governing body. If I remember right the comment used was " she thought...... " , not based on clinical findings. As most have all agreed there is no new clinical findings yet. So changing things seems a bit premature, considering what the consequences may be. Nobody interpruts protocols, differently, that's why we have them. Set lists and algorithms for set procedures. Stopping a bleed is what we are to try and do, if we don't, we haven't failed, we merly do what we are taught to do, and work to our best. If you have a closed bleed with raising ICP, follow what you have been taught, don't get you trepaning kit out and crack on, we don't do that. Protocols are there for a reason. If we didn't follow them we would not be employed. Yes, they are to be held in high esteem it's what we get paid to interprut. Gordon maybe you should think befor you say some of the stuff you just did. It seems you're not being very diplomatic. . gordon scott <gordonscott18@...> wrote: Maybe this lady should be given the chance to produce the evidence base to support her teaching. She may or may not have said it, but as the list at the moment is undecided as to what to do once you have the large bore needle in, maybe she should have the chance to explain and produce evidence for the argument. Protocols are great but from the chat so far you obviously have none or they are interpreted differently. Everybody is agreed you must put in large needles but then the list has said 1. put lots of fluid in. 2. put big needles in and then control their hypotension. 3. put big needles in and then just enough to get a radial pulse. 4. put in big needles and then titrate to the bp. The only protocol I can see that she has broken is the one that says you must put in big needles (If of course you can) If the problem is the bleed can not be stopped how does the list propose to stop the bleed without access to a surgeon so they can resuscitate? What size of needle do I put in if it is trauma but that trauma is a closed head injury in isolation with a rising ICP and once it is in what do I do with it? Not trying to stir the mire, I just thought you may be able to tell me from the protocols you all have and hold in high esteem and never diviate from!!! >From: " steve benbow " <sbenbow@...> >Reply- > >Subject: RE: Cannulation and shock >Date: Wed, 13 Mar 2002 09:38:41 +0000 > >I would be interested what else she is advocating.... I bet theres a rake >of >misinformation. bet shes still using EUSOL. > >cheers Steve > >Stu, good to see your about, I belive you volunteed me for Tig! > > > >From: " stuart hamer " <hamerstuart@...> > >Reply- > > > >Subject: RE: Cannulation and shock > >Date: Wed, 13 Mar 2002 09:28:26 +0000 > > > >Sounds like an unfounded pet theory thing she has going, It would surely >be > >a lot more " barbaric " to have a hypovolaemic patient expire on you due to > >inadequate fluid replacment. > > > >Cheers > > > >Stuart > > > > > > >From: " Brash, \\ Lines, Gavin (amed2) " <amed2@...> > > >Reply- > > > " ' ' " > > >< > > > >Subject: RE: Cannulation and shock > > >Date: Wed, 13 Mar 2002 02:41:32 -0600 > > > > > >Her advice is contrary to all current ATLS protocols, I would certainly > > >like > > >to see her supervisors reaction to these views as well as the companies > >who > > >are paying for their folks to be trained ( badly). I agree that in > >someone > > >shut down 18G may initially be all you can put in sometimes not even > >that, > > >But whenever possible in trauma the largest shortest cannula which >gives > > >the > > >largest flow rate should be used..... > > > > > >Nuff said > > > > > > Brash > > >Senior Nurse Supervisor > > >Cabinda Gulf Oil Company > > >e-mail: Amed2@... > > >Telephone: CTN. 8 345 2696 > > >Via London 020 74878100 Cabinda Ext. 2696 > > > > > > > Cannulation and shock > > > > > > > > Hi Folks, > > > > Just thought you might find this interesting. I was at > >MRI > > >at > > > > Stonehaven on Monday for a day ( unofficial chat about things in > >general > > >) > > > > and one of their nurses that trains the medical Aiders on board the > > >rescue > > > > vessels seems to have a different view on cannulation in trauma. At > > > > present all rescue vessels carry sets of cannulas of the usual sizes >- > > >14 > > > > , 16 , 18. > > > > Tthe training that I have in trauma ( having just done my trauma > > > > management refresher ) states that in shock for adult volume > >replacement > > > > you use 14 / 16 gauge in order to get a rapid flow rate. 18G being > >used > > > > for drug admin etc. This nurse is now telling me that she advocates > >the > > > > use of the 18g cannula alone, even in serious trauma , and that we > > >should > > > > take off the other two sizes of cannula. She does not like the large > > >size > > > > of cannula, saying that it is ' barbaric'. As far as I am aware she > >does > > > > not have any formal pre-hospital quals and was hospital based for >most > > >of > > > > her career. > > > > I checked all my stuff and the JRCALC rules and they all say for > >rapid > > > > fluid admin use 14 / 16 g. > > > > I also met this lady on tuesday at an OPITO meeting where she >tried > >to > > > > get the 14 / 16 g cannulas removed from the equipment lists. This >move > > >was > > > > blocked. I would be interested in your views on this. > > > > Regards to all, > > > > Andy > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2002 Report Share Posted March 14, 2002 Gordon, I suspect we are playing from the same deck of cards, I agree in remote locations things are difficult, and sometimes people die. Operator skill is obviously a factor and some fluid is better than no fluid. However, my thoughts are that until the " experts " with the research come out and say ok chaps a small butterfly is all you need, We should all be teaching or be taught the large and thick, I Just completed my renewal in Aberdeen and that is still advocated there, last Sept. I did the ATNC \ ATLS in Belfast and once again they are still teaching the short and thick the Prehospital courses are also teaching the same thing., the hypotensive resus. is still in it's infancy and being researched. If we have centres all round the country teaching different things then the whole thing will turn to rat S#*t as it was before the advent of ATLS type care. OK promise not to say anything more about Cannula's. . Brash Senior Nurse Supervisor International SOS \ Cabinda Gulf Oil Company e-mail: Amed2@... Telephone: CTN. 8 345 2696 Via London 020 74878100 Cabinda Ext. 2696 > Cannulation and shock > > > > > > > > > > > > > > Hi Folks, > > > > > > > Just thought you might find this interesting. I > was > > > at > > > > >MRI > > > > > >at > > > > > > > Stonehaven on Monday for a day ( unofficial chat about things > in > > > > >general > > > > > >) > > > > > > > and one of their nurses that trains the medical Aiders on > board > > > the > > > > > >rescue > > > > > > > vessels seems to have a different view on cannulation in > trauma. > > > At > > > > > > > present all rescue vessels carry sets of cannulas of the usual > > > sizes > > > >- > > > > > >14 > > > > > > > , 16 , 18. > > > > > > > Tthe training that I have in trauma ( having just done my > >trauma > > > > > > > management refresher ) states that in shock for adult volume > > > > >replacement > > > > > > > you use 14 / 16 gauge in order to get a rapid flow rate. 18G > >being > > > > >used > > > > > > > for drug admin etc. This nurse is now telling me that she > > > advocates > > > > >the > > > > > > > use of the 18g cannula alone, even in serious trauma , and > that > > > we > > > > > >should > > > > > > > take off the other two sizes of cannula. She does not like the > > > large > > > > > >size > > > > > > > of cannula, saying that it is ' barbaric'. As far as I am > aware > > > she > > > > >does > > > > > > > not have any formal pre-hospital quals and was hospital based > >for > > > >most > > > > > >of > > > > > > > her career. > > > > > > > I checked all my stuff and the JRCALC rules and they all say > > >for > > > > >rapid > > > > > > > fluid admin use 14 / 16 g. > > > > > > > I also met this lady on tuesday at an OPITO meeting where > she > > > >tried > > > > >to > > > > > > > get the 14 / 16 g cannulas removed from the equipment lists. > >This > > > >move > > > > > >was > > > > > > > blocked. I would be interested in your views on this. > > > > > > > Regards to all, > > > > > > > Andy > > > > > > > > > > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2002 Report Share Posted March 14, 2002 Lets not forget that if you have a " small bore " in and did it becasue you didn't want to be barbaric.......then the patient makes alive to the hospital and they descide too transfuse blood to replace the fluid lost.......suprise you need to stick the patient AGAIN! Causing more pain. Granted your prehospital line is going to get pulled anyways sooner or later but we are talking Major trauma/ fluid comprimised patients. So which is better? once or twice? Tom >From: " Brash, \\ Lines, Gavin (amed2) " <amed2@...> >Reply- > " ' ' " >< > >Subject: RE: Cannulation and shock >Date: Thu, 14 Mar 2002 07:47:48 -0800 > >Gordon, > >Protocols are in place as guidelines, Surely it is safer to put in a 14 - >16 >gauge cannula " Just in case " rather than a small one and then find >yourself in trouble. Even with controlled Hypotension 14 - 16 g is still >advocated. > >Hell I think the lady should be allowed to say her piece, And if her >teachings are evidence based than... Good for her, however I can't imagine >any traumatologist telling us to use an 18 or 20 gauge cos it's much kinder >!! > >. > > Brash >Senior Nurse Supervisor >International SOS \ Cabinda Gulf Oil Company >e-mail: Amed2@... >Telephone: CTN. 8 345 2696 >Via London 020 74878100 Cabinda Ext. 2696 > > > Cannulation and shock > > > > > > > > > > > > Hi Folks, > > > > > > Just thought you might find this interesting. I was > > at > > > >MRI > > > > >at > > > > > > Stonehaven on Monday for a day ( unofficial chat about things in > > > >general > > > > >) > > > > > > and one of their nurses that trains the medical Aiders on board > > the > > > > >rescue > > > > > > vessels seems to have a different view on cannulation in trauma. > > At > > > > > > present all rescue vessels carry sets of cannulas of the usual > > sizes > > >- > > > > >14 > > > > > > , 16 , 18. > > > > > > Tthe training that I have in trauma ( having just done my >trauma > > > > > > management refresher ) states that in shock for adult volume > > > >replacement > > > > > > you use 14 / 16 gauge in order to get a rapid flow rate. 18G >being > > > >used > > > > > > for drug admin etc. This nurse is now telling me that she > > advocates > > > >the > > > > > > use of the 18g cannula alone, even in serious trauma , and that > > we > > > > >should > > > > > > take off the other two sizes of cannula. She does not like the > > large > > > > >size > > > > > > of cannula, saying that it is ' barbaric'. As far as I am aware > > she > > > >does > > > > > > not have any formal pre-hospital quals and was hospital based >for > > >most > > > > >of > > > > > > her career. > > > > > > I checked all my stuff and the JRCALC rules and they all say >for > > > >rapid > > > > > > fluid admin use 14 / 16 g. > > > > > > I also met this lady on tuesday at an OPITO meeting where she > > >tried > > > >to > > > > > > get the 14 / 16 g cannulas removed from the equipment lists. >This > > >move > > > > >was > > > > > > blocked. I would be interested in your views on this. > > > > > > Regards to all, > > > > > > Andy > > > > > > > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 14, 2002 Report Share Posted March 14, 2002 See, I've been saying this for years, Give Keogh to the Navy and it all goes to rat shit! . :-) ihub999cht@... wrote: Anyone that has been through Keogh in the last couple of years will have been taught this. Ian H Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 15, 2002 Report Share Posted March 15, 2002 , thanks for your comments. I am aware of protocols. I am also aware of the array of diffent protocols and that they change. They are in the main for first world and not remote medicine, we can not ignore them but we must take everything into consideration. The scary thing is there are some people who follow blindly and do not look at the evidence base. Let's take your comments about the 30 degree headup position from the AHA. I have been taught the CPP=MAP-ICP. There are schools of thought that say a 30 degree head up position affects the MAP and will reduce CPP. There are also those that say a rising MAP will increase a bleed. What do your protocols say about this? As for your comments about " been there seen it and done it " I have phoned someone who is suspicious of your comments and says that I should ask you to supply the date for the up and coming reunion. That if you have as you say been there and seen it you will be able to confirm the date. Not the venue! Regards >> > Gordon, have a read back through what's been said and you see that most >of what has been said relates to possible future new recommendations, not >what we have on protocols. Now if you don't know protocols, where they are >and what they are, pray tell, what are you doing in this job? Gordon maybe >you should think befor you say some of the stuff you just did. It seems >you're not being very diplomatic. >. > > > > > > _________________________________________________________________ Get your FREE download of MSN Explorer at http://explorer.msn.com/intl.asp. Quote Link to comment Share on other sites More sharing options...
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