ERDoc

This case just shouts BAD!!!! First off, we have a 90-something year old with belly pain and bad vital signs. Divertic is a possibility, but I wouldn't want to hang my hat on it yet. It would be nice if our ambulance has an US machine, we could do a FAST exam to look for evidence of blood in the belly (really bad given the coumadin). Again, all I think of with this scenario is BAD!!!

The lido may or may not have been needed (I wasn't there, so I can't judge). The EMS director needs a little re-education (or as recently been discussed in other threads, some education period). I hear the vollies where I work always getting mad because we repeat things that they do when the pt arrives in the ER (retaking the history, doing our own EKG or our own finger stick). I think this is a perfect example of why. You should always do your own assessment, regardless of how much you trust the person that is giving you the info. If you document what they tell you and then it ends up in court, you will hang. To make a short story long, this actually reminds me of a recent case. At the university hospital that I work at we have a code BAT (brain attack team) for when a stroke pt comes in that may be eligible for thrombolytics. When the code BAT is called it activates the stroke team (Neurology, CT, MRI, ICUs). We had a pt come in that was a code BAT. So she gets into the room and we start working on her. About 5 minutes after the neuro team is in the room our triage nurse announces that another code BAT is coming back. The neuro resident offers to go do the initial assessment. After I finish my part with the first pt, I walk into the other room and the neuro resident walks out saying that she is done. I ask her what she meant and she says the lady has a finger stick of 10. Yup, this particular nurse is a little over aggressive, but has the best intentions.

This is one of those situations where it depends on your pt. Those with a low pain tolerance will be screaming like they have a 2 foot kidney stone, while others will just describe it as annoying. Personally, I'm a big fan of aerial spraying of valium, percocet, diaudid and zocor.

This is kinda off of the topic, but what does the J stand for?

No drugs, but in case the unit started to go south and the pt became unstable it might be good to have ALS. I would put on a monitor and definately get a line going.

Unless you have monitoring capabilities I would not use a magnet. The pt needs to be put on a montior, but depending on your proximity to the hospital it might not be worth waiting for ALS. If the AICD is firing because the pt needs it, it is doing its job and doing it correctly if he is still conscious. You may want to have the AED out just in case, but let the AICD do it's job. If it's malfunctioning, there is not much any level of prehosital provider is going to do about it.

Here is a link to a great article on cocaine toxicology from emedicine: http://www.emedicine.com/emerg/topic102.htm I stand corrected as to one of my previous posts. Labetalol has a 1:7 ratio of activity on alpha:beta receptors, so it is not the best choice. Looks like we all learn something from these scenarios.

It sounds as if everyone is in agreement on ntg (although you would need to watch out for reflex tachycardia). ASA is not a bad idea, won't hurt in most cases. Someone mentioned beta-blockade for BP. This would be BAD. Cocaine is an alpha agonist. If you block just the beta receptors you have unopposed alpha activity, which causes vasoconstriction, worsening the already bad MI, increasing the BP and possibly leading to stroke. This is the one MI where you NEVER give beta-blockers. You can start with something like labetalol which has both alpha and beta, or you can go with other options. This guy is having a cocaine induced MI, which is not all that uncommon.

There is no tenderness/pain is not reproducable. The pt was chatting with some friends about the theory of relativity and its relationship to the season finale of Grey's Anatomy. This is his first time speedballing. So it sounds like everyone wants to see a 12-lead, so here it is.

No LOC. VS 210/106 118 22 Pt takes no legal drugs, but says he has taken a few speedballs and has been drinking some Crazy Horse. No herbal suplements. The pain is crushing and he is diaphoretic and nauseous. No sob. LS CTA b/l.

How progressive do you want to be?

You are called to a private residence where there appears to be a party going on. Your pt is a 32y/o male with no PMH who is complaining of sudden onset of left side chest pain that started while he was talking to some friends at the party. (VS-eh, should we let this one walk? )

There are no visual differences in the legs. Pt can push and pull equally on both sides. Only med is a beta blocker for her htn. There is no h/o syncope. DTRs and babinski intact. Great question about hoarseness, but there was none. The pt says the best she can describe it is like pins and needles starting. The left DP and PT pulses seem to be decreased compared to the right. VS now 180/102 106 16 100% on NC

Nothing makes it better or worse. 12 lead is unremarkable. O2 on and no change in pain status. "Hey, my left foot is starting to feel a little funny."

Punisher, I've been following that since it started. I think bstone is exactly the reason EMS will have such difficulty going beyond where it is now. Quite unfortunate. Interesting discussion though.

:happy6: OUCH, Rid you made my head hurt. :sad4:

LS CTA b/l, Nl s1s2, no m/r/g, no pulsus paradoxus (care to explain what this is for those that don't know)

Pt states she was the restrained front seat passenger in a car that rearended a stopped car. She was enagaged in a deep converstion over adult incontinence garments with her friend Bertha at the time so she doesn't know exactly how fast they were going, but guesses the speed to be about 30-40mph. There were no airbags in the car. She was ambulatory at the scene and refused EMS and had no LOC. She has a h/o htn and chronic upper thoracic pain that was a little worse after the accident. This pain is definitely different. It is a constant achy pain that does not change with movement. She denies any anterior pain or trouble breathing. VS 162/98 104 16 99%RA Neck is nontender as is the rest of the spine. Pt is A&OX3 with GCS=15. Pt is able to move all extremities and has nl sensation.

Sorry, my daughter took the horse to take the kids to school and then she has some running to do. ](*,)

You are called to the residence of a 72y/o female with upper lumbar back pain. She was in an MVA 2 days ago. Have a nice day. :glasses5:

BINGO!!!!! :D/ I have yet to hear any indications for xrays, just rx and dc.

I would guess it is because your partner is uneducated as to the purpose of the board. It probably wan't a bad idea to put the pt on it so that it would be easier to move the pt, but once on the hospital strecher there is no need for it. It will only cause more pain (and possibly ulcers).

All of those procedures are used in more than just the trauma setting. There are plenty of medical pts that get central lines and chest tubes. Standard of care for septic shock is a central line. Even those docs that aren't in a trauma center does these day in and day out (although the chest tubes decrease in frequency dramatically outside of a trauma center).

Au contrere: http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum and my personal favorite... http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum You will not find literature on the success rate of surgeons at intubation because they just don't do it. It's like trying to find literature on paramedics doing colonoscopy. Although, I did have a surgical resident ask if she could attempt to intubate a trauma pt once. Perfect esophageal intubation on the first (and last) attempt. So, based on my study with an n=1, they need to be remediated in their intubation skills (though I don't think my power will be very high if I took the time to calculate it). Each specialy has its own scope of practice and when there is a procedure that needs to be done, they consult the appropriate specialist. I would never let an ER doc take out my gall bladder, but I would have no problems with them dropping in a central line. I would never let a surgeon do an LP, but give me an ER doc or neurologist and I would have no problems.

No wonder my job is so boring, you field guys get to have all of the fun . My friend, I hope this is a typo, but if you truly did this and were still able to breath on your own, you need to seriously consider AA.