ERDoc

He seems to be having problems with his short term memory. He remembers going camping over the previous summer in upstate NY. He remembers starting school in Sept. He evens remembers some things from this morning (This is about 9pm in late September on Long Island, NY). There does not seem to be any pattern. There does not seem to be any selective about the memory loss. The parents have not noticed any balance problems. They have not noticed any staring episodes. As you question him he seems to try to fill in the details that he cannot remember. He seems a little embarrassed about the entire situation.

The parents deny any h/o diabetes or seizures. There is no recent head trauma that the parents can recall. The pt denies drug use, even after the parents leave the room. They say he is a straight A students and doesn't hang out with the kind of kids that use drugs. There are no trauatic events that the parents are aware of. We will get to VS and PE once we have completed the history. Is there anything anyone else wants to know about the history. For the record, this happened in late September (if that makes a difference to anyone).

PMH significant for asthma, but has not used his MDI in several years. Other than the MDI he doesn't take anything. He is on his school's soccer team. The pt isn't sure, but doesn't think he hit his head. The father says that the coach called a little while ago and said that while the pt was at practice today he was running down field and suddenly veered off to the sideline. When the coach asked him what was wrong the pt looked kind of blank and said he wasn't sure. The coach had him sit out the rest of practice. The coach did not see him hit his head at all. After practice the coach asked him what happened and the pt could not remember.

It's been a while since I have had a case worthy of becoming a scenario, but finally I have one for you all. You are called to the home of a 15 y/o male whose parents called because they noticed he couldn't remember anything. The pt is denying any headache and offers no other complaints. The scene is safe and the parents are with the pt and visibily upset. What history do you want to know?

Bet he had the clearest lung sounds you've ever heard.

Just another note, people with chronic DIC are usually on coumadin or heparin. It is not a diagnosis you will see very often.

I think with someone like this, you need to be a little more forceful. When the risks are explained, I would not say, "you could die," I would try something more along the lines of, "you will die." Also make sure the family hear this. I'm going to guess that this wasn't a very educated family and they did not understand the full consequences of his underlying problem. Sometimes you can educate till your face turns blue, but you are only ](*,)

Doesn't matter who made the machine, they suck at reading EKGs. Irrelevant who made the pacer.

There have been several recent studies that show MOI does not necessarily correlate with injuries. In my experience (no studies to prove it) the brain is much more easily injured that the spine. I'd be curious to know if that pt would have been cleared by NEXUS before he went out. Also keep in mind that the NEXUS criteria (or the CCS rules) are neither 100% sensitive or specific, but you won't be able to find anything that comes as close.

Head injury does not equal c-spine injury. If they are conscious when you see them and you are able to clear them, how are they going to sustain a cspine injury before they lose consciousness again? At the hospital we will not dismiss the LOC at the scene, they will usually end up getting a head CT (even this is currently being debated in the literature, but I am not that brave). Honestly, if you end up bringing in a pt that was conscious and then became unconscious, their neck is going to get imaged anyway. One thing that the NEXUS criteria did not address is age. I will not usually use NEXUS in elderly pts.

I just wanted to clear up some apparent confusion about the NEXUS criteria. In order to clear someone clinically, they must meet five criteria: 1. No posterior midline cervical spine tenderness is present. 2. No evidence of intoxication is present. 3. The patient has a normal level of alertness. 4. No focal neurologic deficit is present. 5. The patient does not have a painful distracting injury Pretty straight foward, right? Nope. I have worked with one of the authors of the original study. Here are a few notes for you. #1 is pretty straight forward. #2 pretty straight forward also. #3 this means when you examine the pt, it DOES NOT matter if they had LOC at the scene, as long as they are fully alert now, you can clear them (obviously this is where the field may be different from the hospital). #4 refers to numbness, tingling, paralysis, etc in an extremity. #5 is probably the trickiest. This is where clinical judgement comes into play. What one person feels is a distracting injury, another may not feel is. There were no specific criteria for what constituted a distracting injury in the originial study, it was at the doctor's discretion. Different people have different takes on it. Hope this helps a little. As far as being able to use NEXUS to decide not to immobilize, why not? A c-collar is inteded to keep the neck immobile until an injury can be ruled out. If you can rule out an injury with the NEXUS criteria so that you do not have to xray/CT it, what purpose is there in applying a collar? As for the comment about the arrest at a doctor convention vs an EMS convention, that may be true at most conventions (when was the last time your pathologist did CPR?), but I must say that it does not apply to an EM convention (sorry, just had to set the record straight ).

First off, -5 for depending on a machine to do your assessment (tips hat to Dust). Most machines have terrible ability to interpret anything that is not NSR. They are good for assessing your intervals, assuming that your rate is not too high or the voltage is not too low. NEVER depend on the machines results. A paced rhythm is pretty useless at looking for much. You should be able to see AFib however. In most cases it is going to look like a ventricular rhythm/BBB. Although, this depends on what kind of pacer they have.

OK boys, put the tongues back in the mouth (feel free to PM me with the details). Firefighter, there is no evidence based standard of care. As I stated previously, there is no evidence in either direction, so your standard of care is based on what your medical director likes to do this week. It is obvious that your 12 years of experience has taught you very little about the real world of medicine. The small amount of education that I have has taught me that osteomyelitis is a bitch. It is not as simple to treat as cellulitis or pneumonia. We are talking months of antibiotics, multiple hospitalizations, PICC lines (check it out if you don't know what it is). It can take over a pts entire life and still lead to loss of the limb. The antibiotics are no joke either. We're talking some of the big guns for osteo, which can reek havoc on a body. If they are diabetic or immunocompromised for any other reason, it gets even worse. Give me an educated person anyday and I can quickly mold them into an experieced provider. I don't think the same can be said for the opposite.

Sighs in frustration...

Especially for newbies, always remember to offer to wash the doc's car. :wink:

Experience is what you gain after a mistake is made (hopefully not yours). -Heard during medical school

Doesn't seem like these skills are of any use if you can't use them to care for the pt. I imagine even an EMT could pass along the message to the ER that the pt has RUQ pain. I still don't see why this needs a medic, especially if there are no ALS supplies.

When I was in the field in NYS, this issue came up. We contacted the state and were told that on a BLS call an ALS person is not acting as an EMT-CC or paramedic, but as an EMT. Due to this, they are able to transfer care to another EMT. Obviously this pertains to NYS and may vary by state. I seems like a waste of resources to force an ALS provider to take a BLS call when there is a BLS provider that can take it.

Between rounds I did a literature search on Pubmed. There is relativley literature to support the use or non-use (is that a word?) of traction splints. Here is what I have found so far: http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum As you can see it is not much. There really is no good evidence to support or not support the use of traction. I like the thinking of the orthopods that Asys talked to. Any open fx is going to end up in the OR for washout and repair anyway, reguardless of what you do in the field.

Playing Monday morning quarterback, this call reeks of chole, not really an ALS issue. It is situations like this where better education (or any education for that matter) might be helpful. I've seen 3 of the 4 Fs so far (female, 40, fertile). Be cautious making generalizations such as the one that your instructor made. Most abd pain needs not to be taken serious. ABd pain is one of the most common ER complaints and we fail to find a cause in about 80% of the cases. I have seen serious pathology present as just a vague, mild discomfort. One of the most painful causes of abd pain believe it or not is gas (not exactly an ALS call). Looking at the two concerns you had AAA and ectopic, what is ALS going to do anyway? Both cases need a surgeon (not even an ER doc). The best treatment in the field for both would be diesel. Even in the ER, treatment is going to be quick bedside US and a call to the appropriate surgeon. I am also assuming in this case that the pt's vitals were wnl. One way to address the medics in this case is to ask them what they think is going on. Find out what their presumptive diagnosis is. Then ask them if they are OK with it going by BLS. Obviously is there is some sort of abnl vital or something going on, push a little harder. You need to be an advocate for the pt to make sure that they get what they need.

You know, after reading this and several other posts with the whole ALS/BLS debate, I'm glad I work in the hospital where we can provide pt care. This system is so fractured, is there any chance of repairing it?

There is nothing really wrong with a tourniquet. As someone previously said the greater area you can spread it out the better. I use them all of the time to control bleeding from a wound that I am trying to suture. It stops the bleeding so that the wound can be explored (can be pretty difficult if blood keep filling your field). In the time it takes to get the pt to the ER a tourniquet probably will not do much damage. If they are in a position to need a tourniquet, they probably have much more serious things that will almost be guaranteed to kill them. Don't be too afraid to use one.

If you want to learn EKGs, browsing is not the way to go. The best way to learn them is to read about them, know the pathophysiology going on and then look at them over and over. As recommended in the other post, read Dubin to get familiar with the basics and then read Garcia to get the good stuff.

This may sound stupid, but who's providing the pt care?

OK, I think I have managed to make this one drag (Hello, becksdad!) on long enough. Your radiologist calls you and tells you that you need to have a heart to heart with the pt because she has a mass in her brain. I know this is not something you will be able to dx in the field, but she has the classic presentation so you may be able to make an educated guess should you come across it. Different headaches present differently. What is important in this story is the headache that is present when she wakes up and goes away after she has been upright for a while. The headache is caused by the pressure of the mass cutting off the outflow of CSF causing a temporary hydrocephalus. This is relieved when she is upright because the mass is no longer compressing the outflow tracts. Hope everyone enjoyed this one.