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ERDoc

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Everything posted by ERDoc

  1. chbare, you are half right about the LP before CT. There is no problem in doing an LP on someone with a bleed. CTs sometimes miss the bleeds so we actually do an LP to make the dx. This issue, and it is a theoretical one, is that if you have an increased ICP you can cause herniation. This has never actually been shown in the real world, but would you want to be the test case? The CT in this case is negative. Now that she is not shaking you can do a full physical exam. You find nothing including track marks. She is still afebrile and her vitals are stable. There was no recent travel or unusual foods. Rid, all of the labs you mentioned are negative, as is a beta. The neuro team shows up and says, "You have the answer already. Look over what you have and you will see it. Call us if you need us."
  2. She had the PPD as a part of a routine initial physical at the county clinic. The pt had a nl cxr so she was started on INH. EKG is pretty useless due to seizure activity (for those that decided to RSI, it shows sinus tach at a rate of 126). VS BP 167/100, but difficult to assess accuracy due to pt seizing, about 126/72 when paralysed. Tha family denies any recent illness or special pets/herbs/plants. So, let's assume that she has gotten 3 doses of your benzo with no improvement. You decide to RSI her and once your paralytic of choice is onboard, she no longer has seizure activity. Someone brought up a good point here; just because her body is no longer seizing, her brain still is. Obviously not something that can be done in the field, but she needs to be on an EEG monitor. Rid, I will give you a progressive ambulance with a CT which is read by the onboard radiologist as normal. You also have such a long transport time that you perform an LP and get the results before arrival at the ER (sounds like my job may be obsolete) and it is normal. I would not recommend doing the LP without doing the CT first though (extra credit for anyone that can tell me why). Your onboard EEG shows diffuse seizure activity. The husband is now grabbing at you, praising your ability to make his wife "stop shaking. But can you tell me why she is doing this?"
  3. Yup, this was quinine toxicity. The Ophthamologist didn't think she was ever going to regain her sight.
  4. There is no petechiae or rashes and she is afebrile. The only known history that the family is aware of is a positive PPD when she went to the doctor recently. She was born in Central America and moved to the US about 3 years ago. Other than the shaking, her exam is pretty unremarkable.
  5. AZCEP, you are correct. The optic nerve (cranial nerve 2) is pure sensory providing info from the retina. The occulomotor nerve (cranial nerve 3) innervates most of the extraoccular muscles to allow the eye to move (cranial nerves 4 and 6 also provide some innervation). You have some good thoughts. chbare, your ambulance also has its own MRI (you work at a very progressive ambulance service ). The MRI is also negative. The husband says that when he returned he found the pill bottle empty and many pills spread throughout the house. He says it looks like she did not take all of her oxy and methadone. It appeared that the BP meds were taken appropriately. There were no qunine left, including the ones that were in the bottle in the cabinet. So, what do you think now?
  6. The husband says that she has never had seizures before and there is no history of trauma, although she is recently from Central America and did not have much medical care there. The family also says that the pt does not drink, smoke or take any illegal drugs. She has not been sick recently. She was sitting at the dinner table talking with the family and just fell over and seized. There are no known allergies. As far as the husband knows she is not pregnant, "But I guess anything could be possible." The pt weighs about 180 lbs (sorry my Canadian friends). Her FS is 134. You put in an NPA and start an IV. You give your benzo and get no response. What do you do now? Is there anything else you want to know?
  7. The seizure is gneralized/clonic-tonic/grand mal (take your pick). She is foaming at the mouth and you her gurgling sounds. There is a good, strong pulse. The son is not looking for anything in particular, he just doesn't have anything else to do.
  8. Husband is not sure, but he doesn't remember them being so big. Do you really think at this point that you can feel comfortable to a physchiatric dx? Would you feel comfortable sending this wman home if you truly believe it to be a psychiatric cause?
  9. You are called to the house of a 43 y/o female who has been seizing for the last 10 minutes. The son is running around the house like he is looking for something but can't find it. The daughter is at the pts side, crying, saying, "Mommy don't die!!" The husband is leaning over the pt saying, "Damn, I never seen anything like this before. Can you guys do something to make her stop?" What do you do?
  10. Sorry I haven't answered any posts in a while. There was some good discussion going on and I didn't want to pollute with more info. The husband says that the pt has been clean for almost 5 years. He says that this is her normal mental state. He left on Friday and came back today (Monday). He normally handles her meds, but since he had to leave he left them in one of those pill bottles that have the days of the week on them. The quinine script is not new, she has been using it for leg cramps every since the back injury. Ethnicity is whatever you want it to be (she does not have G6PD). AZCEP: There is no facial droop, arm drift or slurred speech. How would optic nerve compression limits your ability to move your eyes? chbare: I will give you your pixie dust. EKG is unremarkeable, CT head normal, tonometry reveals IOPs of 10 on the left and 12 on the right. What are you looking for with a slit lamp (there is no corneal abrasion or hyphema)? She was on interferon about 7-10 years ago, but has not followed up with her GI doc, but the husband thinks her last set of labs were normal. There is no jaundice. Her ammonia level is normal. Even with the pixie dust, the quinine level is a send out lab and has to go to a lab 2000 miles away (which you find out after a 30 minute discussion with the lab that you have in your ambulance). There are no track marks that you can see. Her neuro exam is pretty normal, execpt for the blindness (she does not respond when you present a threating stimulus to her (you make it look like you are going to hit her)). Hope this helps, and it actually reminded me of another case (see you in the next thread).
  11. Your pt is a former heroin abuser and also has a h/o htn, herniated lumbar disk with chronic back pain and Hep C. There is no h/o trauma. She is taking atenolol, norvasc, quinine, oxycontin, robaxin, motrin, methadone, lasix and Kdur. FS is 106. 114/68 68 14 98.2.
  12. Pt is not able to answer questions well, but from what you can get from her the vision loss was gradual. It started centrally and has progressed outward over the period of 2 days. No headaches or eye pain. There is complete loss of all visual fields. Pupils are fixed and dilated. I think this puts conversion higher on the ddx .
  13. You are called to the house of a 43 y/o female by her husband. He has just returned from a family emergency out of state and found his wife unable to see and a bit confused. What else do you want to know?
  14. Guess the doc isn't going to be able to get too much more info from the pt. I would first reasses ABCs, confirm tube placement, manual BP by my well seasoned RN. Completely expose if not done already. We need a full trauma workup including xrays (chest, pelvis, femur, hip, knee), CTs (pan scan at this point), labs (basics trauma labs plus cadiac enzymes (will be positive at this point), BNP, Dig level, ABG with K), blood and call trauma team, if we have one (no medical team would touch this pt due to the fall, his life depends on the surgeons (hope he's made his peace with whatever god he beleives in)). Need to drop in a cordis in the IJ for TVP and a femoral cordis for blood/pressors/etc. 12 lead would be nice. Would also be thinking about dropping in some digibind. Let's start there and see where it gets us.
  15. I think that given the fact that he was dx with a URI, antibiotics, regardless of which one, is a poor choice. I'd like to know what the throat looked like. Was there any stridor?
  16. I was working renal roundup with a relatively new EMT. We loaded the pt up after her treatment and as I jump in the driver's seat, I hear my partner ask the pt, in a very serious voice, "So, do you feel clean now?"
  17. In some areas you don't get a choice. The county I am in is run by a volunteer system, with some companies having paid first responders (there is also a large number of volly ALS personel). There is no guarantee what you will get, it's a crap shoot. Pretty pathetic for one of the largest volly systems in the country/world. The call is dispatched to whoevers district the call is in and whoever shows up goes on the call. Most of the time there is some form of ALS on each call, but there is no guarantee. We even have a few companies in the area that are not ALS. It's a sad situation that does nothing to improve pt care, but the volunteer system has become such a part of the history here that it will take hell freezing over to change it. Sorry to run on so long, it is just s frustrating situation that will never improve.
  18. While the seizure does sound like a typical seizure, I'm having trouble saying it is glucose related. It sounds to me like he has diabetes and a seizure disorder. People don't take dilantin for glucose related seizures. He also stopped seizing without intervention. A metabolic derangement that causes a seizure will generally continue to have a seizure until the derangement is corrected (although this is not 100% of the time).
  19. I got one... 26 y/o female on her way to EMT-B class is chased down by a bunch of angry people from an online forum who begin to pelt her with various EMS related objects... Just kidding. Welcome to the City. It can be a little rough in here. Edited for Michael's approval (and to post pad )
  20. It gives a new definition to tossing your salad! :twisted:
  21. I got one... 26 y/o female on her way to EMT-B class is chased down by a bunch of angry people from an online forum who begin to pelt her with various EMS related objects... Just kidding. Welcome to the City. I can be a little rough in here.
  22. Each hemoglobin molecule is made up of 4 subunits, two of which are called the beta-globin subunits. The globin molecules are proteins (which are composed of amino acids). In someone with sickle cell, one of the amino acids in the Beta-globin subunit is switched. These modified beta-globins can cause the hemoglobin molecules to clump together within the RBC when they become deoxygenated. It is this clump of hemoglobin that causes a cell to sickle. They have the capacity to carry just as much oxygen as normal hemoglobin molecules. The problem with RBCs that are sickled is that they tend to lyse pretty easily, resulting in an anemia. Someone mentioned reticulocytes, which are precursors to mature RBCs. The body reacts to the anmeia by releasing immature RBCs, aka reticulocytes. In times of severe stress many RBCs being sickling and they start to clump together in the microvasculature casuing a vasoclusive crisis which is usually painful and one of the main reasons that people with SCD seek medical attention. The WBC and platelet counts are ususally mildly elevated, even during non crisis times due to the body's attempt to correct the anemia. Hope this helps.
  23. ERDoc

    Books

    Has anyone ever used the paramedic textbook by Henry and Stapleton? It's an older book, so I will direct this at the veterans.
  24. Here in NY the law allows anyone that is declared brain dead to be declared legally dead and efforts to keep the body alive can be stopped without consent from the family. In my institution there is a lengthy process to declare someone brain dead. The person has to have an EEG and a perfusion MRI to show that the insult to the brain is catastrophic. The pt needs to undergo a full neurological exam by 2 seperate neurologists at least 24hrs apart. The pt needs to be off of all sedatives for 48 hours before these exams. The pt must be shown not to be able to breathe on their own (again, off of all sedating meds). It is a very thorough exam and leaves little room for debate. I saw it once when I was in the SICU. Most of our docs are not as harsh as the one in the story (even the surgeons, at least not in front of the family). It also allows the family time to get everyone together and have time to say goodbye. When looking at stories like this, we need to keep in mind that there is a difference between being in a coma, in a vegetative state and being brain dead.
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