irme

The history of this pt, including lifestyle and lack of GP checkups leads me to point towards LVF. It would appear this pt is suffering from left sided failure only due to the lack of JVD indicative of RVF. As we all know LVF is the most common form of heart failure and is usually followed by right sided failure later on. The wheezes are confusing as they could tend to make some people think respiratory; but as stated this could be (and I think is) just a cardiac wheeze, however with a few other S&S (see below) I would feel comfortable in my provisional diagnosis of CHF (L sided specifically). Rule in LVF - Axis deviation? - Atrial enlargement? (p mitralie sp??) Rule out COPD As most probably know COPD is the suffering of asthma + empysemia or bronchitis (pink puffers/blue bloaters) -Any productive coughs? - mucus production/plugging? - lung sounds ie ?decreased This could still be a COPD but answers to the questions would help in fine tuning my treatment decision… The intresting vital sign here is the HR, it is not tachy which I would have expected for someone failing to be slightly tachy…

The problem with this Timmy is that if the rhythm is shockable the AED will require you to shock and go through all of the rhythm analysis. Most AED's do not let you conduct CPR for 2 minutes. There is massive evedince that hypoxic hearts correlate with poor outcome in cardiac arrest. If you are not EMS trained, used the AED as its meant to be - put it straight on. If its witnissed by you, and your EMS shock immediatley. If its not witnessed by you but effective CPR has been taking place since response I would be inclined to shock. 10% of myocardium per minute remember!

Aaaahh I knew the word didn't look quite right when i pressed "change" on the spell correct! Servant has such a negative connotation, and I didn't become a paramedic to be called somebodys Servant. While I accept crap pay, long hours etc. etc. I do that because its a job I love not because when I was young I wanted to grow up and become some misinformed half wits Servant!!! I don't mind what you want to call me, but don't call me a Servant!

Cause or make the effects of beta 2 agonists ineffective?

Even though I disagree with being sued by the EMT did he really have to use the word servant, it just sounds so degrading!!! Hasnt he ever heard of Euphonisms?

Hmmm, fits 2/3 cushing sydrome, but no cigar.. I would begin to bag this patient to see if there are any changes to pt's condition. Im still thinking cerebral but another possibility is organophosphate posionion (seizures, rhonci) Have no protocol on the use of atropine for organophosphate poisioning nor am i sure it is it. No bottles etc around?

Still seizuring? Place on O2 NRB, try OPA, Naso if that fails. Looking for my causes early, baslines? Pupils? BSL? Posturing? Ask for a pmhx incl meds and ask her to define confusion. Also how has been "unwell"? Working diagnosis should include cerebral (Needs vitals, pupils, posture), BSL (check them duh, epilepsy (mhx), pseudo (futher assesment) Ill stop for now and await some answers

To me the magic of education amplifies your ability to use inclusive medicine treatments and examinations coupled with evidence based medicine to make better clinical judgements. One example I constantly see in relation to this is MI’s in females. The “textbook” chest pain patient was originally based on male patients ignoring female MI’s. As a well educated paramedic you have clinical judgement that when you have a pt with epigastric chest pain and vomiting you wont immediately say “oh here is abdo pain”. Instead you have that realisation that pain around the body is often referred and that to assume it is abdo pain goes against every ounce of higher education training you have been given. Lack of EMS education is negligence via ignorance – that doesn’t make it ok!

One thing to be weary of is ever choosing pride over patient benefit. That being said one can sympathise your situation. However a move forward technologically would be to have the benefits of 12 lead transmission. Different texts state different rules for the MI. Hell a depression of 0.5mm should be considered as possible MI according to one of my text books (that half a square). In my service 12 lead ecg’s are seen as often more important than IV access because if you can transmit an ECG that indicates an AMI you will get the staff at hospital into action and awaiting your arrival with a team versus a single triage nurse. At the end of the day your clinical interpretation of an ECG hasn’t got squat to do with the treatments the individual will see at the hospital, they are going to take their own and base their treatments on their ecg findings

Asys is putting foward the job he did that many would have "written off" the pt as dead. It is a seperate job to the one you posted originally just one with similar traumatic injury!!

As above!!! Glucagon is a backup option when IV access is likely to be delayed or impossible due to pt presentation, can you even buy glucagon as an IV option!?

Personally I have never seen asytole spontaneously convert to vfib .. I wont reserve judgement, the pt should have been shocked clearly. Now the question is why not? Gear not working? Didn't have pads? Who knows, all i know is it is criminal to lose (or equivalent) a person of that age who has arrested in front of you!

Really interesting video and overall they (the lifeguards) did a sufficient job. Early recognition of inadequate respirations and early defib access being the two most impressive. In terms of what they are – lifeguards I think they did a good job. A nervous lifeguard will never find a pulse like that of a paramedic that has gone to 30 arrests this year. If I was to critique their care I would suggest earlier CPR (and faster!), to me this was slow in beginning (they noted he had no pulse but delayed CPR). I would suggest earlier airway control. They got him back after 3 shocks and so therefore that would indicate 6 minutes of BLS prior to the guy holding an OPA in his hand (assuming it’s a new defib) Like I said these guys are lifeguards and did a good job for their levels of training. One other point could be to have a clear leader take control of the scene and the pt care, there were quite a few chiefs in there! Good job boys, you saved another one!! As a side note that narration makes me cringe – maxalon to help stabilise him (must be our new miracle drug!!!)? And 3 shocks means he has no chance at living? My stab at this would be a hypoxia based cardiac arrest. I would have thought he would present in PEA especially at that age. Looks to me those “spasms” they are talking about is decorticate posturing; airway, airway, airway!

See that’s where I beg to differ. We have two possible scenarios 1) The pt is being annoying but completely competent. 2) The pt is not competent and needs transport as obviously her judgement is impaired. You think that she falls under scenario 1 but in reality it is impossible to place her into that category and to do so would be so assumptive on your part that you start to walk towards showing negligence. If however you chose to talk to her about the reasons she needs to answer your questions appropriately and that if she does so she will illustrate her ability to make informed choices and then she can decide exactly what she wants to happen to her. You are far more likely to get an appropriate response from somebody that is lucid and does not have impaired judgement. Alternatively continue to assume away,..

Based on the limited info provided by the OP this was a sure fire case of kidnapping!! Every pt has their autonomical right to be left alone. The difficulty in this scenario is the fact the pt refuses to commnunicate in a way that can correctly score her mental capacity. I would have: - Calmed the situation, everyone leaves the room so I can have a chat with the pt. Remove the individuals that are inflaming the situation and hopefully this will leave me with a patient willing to be more rational! - Had my partner assatain her normal level of compliance and compared it to this - Explained that if the pt wished to stay here she would need to speak to me properly; failure to do so would mean i couldnt help her gain the outcome she wanted, and she would have to do what everyone else had chosen for her! - Failing that she would need to be transported if she still refused to speak properly to me *You are more likely to have legal action brought against you from a family yelling negligence) and I could assatain from staff and family the pt was not being her normal self.

Lets get some things sorted; witnessed arrsest pre-cordial thump please, get the pads on and defibrillate; start CPR post shock. Now we need to deal with the airway; what about your rescue airway? Failing this go with the cric.. Lets give epi 1mg and look at getting the Amiodarone started; Questions: ?urticaria ? lowered BP prior to arrest ? Known allergies Maybe Poison Ivey, anaphylaxsis or cellulitus

Home defibrillators would be a fantastic idea if they cost couple hundred bucks and everyone could afford them. What is a more effective idea is the implementation of public education coupled with community placed AED’s that were available below the 8 minute mark of EMS arrival. Like I said above AED’s save lives for pt’s who generally have not cardiac arrested before more readily than they do the 80 year old with multiple co-morbidities!!

Without being able to see the study I wonder the kinds of people that were used live with massive co-morbidities; how else would the study presume that these people were likely to arrest? The study shows that the most success was for others not involved in the study (neighbours etc.) with a much higher conversion rate. AED's are clearly invaluable but those living with associated cardiac arrest causes are always less likely to live through cardiac arrest than someone who is having their first MI.. Interesting to read the failure rate and the teaching process; we all know that defibrillating a hypoxic heart is often futile; so I wonder if the delay in getting the machine on the pt and lack of prior 2 minutes of CPR meant the pt's heart became too hypoxic?

Any pain other than his back? What type of pain is it? PQRST Any other complaints? How often has this happened, what normally provokes it? My thoughts, He could be compensating, or as he has had no dr he could just be suffering from hypertension..

A sad reflection on a [s:71c118e6d6]profession[/s:71c118e6d6] with a long way to go

I thought he was 56?? How much does incorrect age on 12 lead affect the results??

You are never going to get rid of the frequent flyers, they are here to stay. They quickly learn an appropriate way to get/demand your attention; what symptoms they need to complain of and how to tug at your emotional strings. As for your average Joe public there are those that listen! What if instead of telling them they get no ride you put it foward as an idea... For instance I ask how the family member is planning on getting to hospital, they usually say follow behind in the car. Now a perfect opportunity to put foward the idea they don't really need to be transported by ambulance. I have always found the key to this is to make them think they have done the right thing in calling us but now the appropriate transport method would be by car. Of course you are always going to have those pt's who refuse and want to go by ambulance but at least you are going some way in reducing maybe a quater to half of the bull that doesn't need an ambulance!

Are you for real? I find it hard to believe you can head on down get a first aid certificate and now start giving out restricted drugs!

Should fire go to every medical EMS gets because "it could be" a cardiac arrest or "it could be" an entrapment? There is no perfect answer, but I am of the opinion that no it isn't necessary. In fact its quite often a pure waste of recourses. In saying that there are always times when it would be entirely appropriate for an ambulance to be on scene - just in case!

Bloods, checking for sepsis. Hmmm non specific abdo pain.. Im thinking maybe peritonitis but still have no idea of the cause! Now the pt is intubated is their any cyonisis? What about skin tenting?