ERDoc

Back to the OP:

I'm one who believes in getting some time under your belt working on the street before spending 10k plus for a degree in Paramedicine.

WHY you ask???

Seen way too many kids spend the money , take the courses and when they get to the job , they find out it's not what they expected and not what they want to do for a career. Once they get past the L&S and the adrenaline rush stage , they end up hating the decision the be a Medic.

But isn't that the way it is with any career that requires a degree or schooling? You don't really know if you like the field until you are done and doing the job. You can like numbers, but once you are an accountant you may hate the job.

I've been involved in medicine since 1991 (but didn't get my first call until Jan 1992), so I have 24 years experience. I hope you crazies haven't scared off the OP.

"strictly part time basis," famous last words.

Welcome, despite the fact that you have been welcomed by our resident psych cases, we are a pretty normal bunch around here. You did the right thing by going right to medic school and don't let anyone tell you different.

The veinlites are fun, but you can't beat an US for getting a good look at the vein.

They are great for getting peripheral IVs.

you said Ambulance Driver, he he he

That was a "hypothetical" statement made by a "hypothetical" patient to a "hypothetical" EMS crew that PD refused to help. The pt was "hypothetically" intoxicated with a "hypothetically" significant head wound that needed evaluation.

But if LE isn't willing to help you get the pt on your stretcher, are you going to risk being hurt by a violent pt? "If that ambulance driver touches me, I will kill him."

Get something like this:

http://www.dickssportinggoods.com/product/index.jsp?productId=12176910&cp=4406646.4413993.4414966.4414980

Cheap and durable. I've used them on scouting trips and when geocaching in all sorts of weather. They are also nice and compact.

Law enforcement, at least locally, is getting out of the medicine business. They have decided that they cannot make a person go to the hospital, even if the person does not have the capacity to refuse and needs to go. They are putting the burden on EMS, who is not equipped or trained to properly take someone who is violent. It's pretty shitty of LE to do that. They don't want any responsibility. I had an officer get pissy with me on a busy Saturday night once. Guy was arrested for DWI (no accident or any complaints) and was taken to the jail where the jail nurse said he was too drunk to be there so he had to go to the ER. He blew a 300+ but was fully coherent and not altered other than a little swagger when he walked (he probably lived in the 300-400 range on a daily basis). I asked him if anything hurt or if he had any other complaints. He denied everything and had a normal exam. The officer was a little angry when I said we were going to discharge and told me that the guy couldn't go back to jail. He didn't seem to understand it when I said that being drunk is not an acute medical issue and there was no need for the pt to be in the ER, taking up a very needed bed. The charge nurse offered to let the office and pt sit in the waiting room.

Would that be considered a case of...BLS before ALS?

I have never cardioverted a conscious person. Most of the time they are unstable enough to be unconscious or stable enough to wait for the nurse to grab the propofol (we tend to skip the consent form and JHACO required time-out).

I'm not sure what your concern is here. You are working within the scope allowed by the hospital (the license you are working under).

Looking at it from the other side (sending facility and receiving facility), this guy should be tubed prior to transfer by the most skilled person (probably the ER doc, but I may be biased). This pt will be spending at least an hour in non-ideal intubation conditions. Let's tube him in a controlled environment with back up devices at the ready (I'm grabbing the Glideoscope). I'm a little concerned about the pt's vitals. He needs fluid resuscitation/blood products going. As for the other guy, at least here in the US, he isn't going anywhere until he has been accepted and the forms have been filled out (seriously, had a tubed head trauma pt that the helicopter was initially responding to the scene for (2 miles from hospital, but got worse so EMS transported to local hospital) and they wouldn't leave the ground until the EMTALA form was completed and they had their copy). Not enough info on the other guy to really make any calls at this point.

Welcome, from another former NYer. We might be able to take this place back from those Cannukistanians soon, if we get more of us.

Yeah I know, but we can all dream. Can't we?

Why can't there be any normal, straight forward patients tonight?

I don't think the OP was thinking he/she is a medic. I think he/she is just concerned about not screwing up at a new job, which I think is a pretty legitimate concern. Yeah, some of it sounded wackerish I think it came from true concern.

I'm pretty sure AEDs fall under first aid now days. I wonder if we have lost the OP.

In reality, all anyone in that situation is going to be providing is first aid. You could have a physician there and all he/she will be doing is providing first aid until the ambulance shows up and takes over. There really isn't any issues here for you. I would advise to skip the mouth to mouth though.

Out of curioisty, is there anyone here who would not have treated hypoglycemia in the field? I accidentally forgot to say that she was a known diabetic. She did have a bit of a UTI and doesn't think she ate before bed so that seemed to be the cause of the hypoglycemia.

You arrive at the local ER where they repeat the finger stick and get 19 (1.06 mmol/L). They push D50 and with 3 minutes the pt wakes up and asks where she is and what is going on. Her neuro exam fully improves. Head CT shows a small scalp hematoma with no intracranial pathology. She recalls all events from the night before. She is watched in the ER for several hours and is sent home when her sugar and temp stabilize. All other workup is negative.

This has nothing to do with the money. The decision to accept the pt was made by the ERDoc, who gets paid the same either way but the decision was left up to the crew since they were the ones who had eyes on the pt. Sorry about leaving off the units on the glucose. It is in mg/dL so for those not in the US it is a level of 1.28 mmol/L. 12 lead shows a NSR without any concerning findings. Sat was 99% on room air. Lungs are clear bilat.

Well, it's beginning to sound like maybe she should have got a CT last night.

It sounds like the family has a pretty good explanation for the fall, it's probably a simple trip and fall. This may be partly a result of all the infirmities of age, a prior ortho' injury, and possibly a bit of Parkinson's developing ("shuffling gate"). I think for confounders, any suspicion of elder abuse? Any recent med changes? Any suspicion of sepsis? While we may have other more pressing issues to deal with, it would be nice to point out to the ER if there are any issues in the home to be aware of, e.g. other trip hazards, need for handrails, walking aids, home care, etc. This is beginning to have the smell of a one-way trip.

Unfortunately, I think even with this good history, we have to c-spine her. If she was 40 years old with this history I wouldn't. This is going to increase her ICP, decrease her respiratory reserve, increase her risk of aspiration, and make intubation more difficult. But, I can't see the ER being too happy if I don't.

ITLS would make this a critical trauma, and we'd be tearing out of there like it's the end of the world. Reality, this has developed over night. Let's get an IV, bG and a set of vitals, and run a 3-lead, and make a decision about where we're going. The 12-lead can probably get done during transport, or as it takes all of two minutes, on scene. I'd pull some blood for an iSTAT en route. It seems unlikely that she's hypoglycemic (although she is old and beta-blocked, which could mask some symptomology) or that this is some sort of atypical seizure activity, but those possibilities should be respected.

It's tough here. She's old, probably has a subdural, but may not, probably isn't a good neurosurgical candidate, and has been sympomatic for an unknown period of time. Palliation is a likely pathway. However, it's not really appropriate to speculate on that until a physician has reviewed a CT. On one hand, the local ED with a CT can do this, ease some burden on the trauma center, and rule out some ddx. On the other, if she does have a significant subdural, we're just wasting time, waiting for secondary transfer.

In an ideal world, I'd call a physican, respect that they have greater knowledge of this area, and ask their preference. This also avoids me having to take responsibility for a decision where there's good reasons to go both ways. Forced to make the decision myself, I would lean towards transporting to the trauma center.

No recent med changes. There is nothing at the scene or with the family that concerns you for elder abuse. Rectal temp is 35.8, other vitals and EKG as previously stated. Finger stick is 23. The family reports no seizure like activity and you do not see anything that you would call seizure like activity. The local ER says they can handle her and transfer her if needed.

Hello,

Thank you for posting.

Lets start with our initial assessment.

GCS?

ABC?

Get her on the monitor and see what happens next.

David

GCS 3, 1, 6

Airway patent and pt is breathing. Palpable pulse with a rate in the 90s.

Monitor shows a sinus rhythm.

First thoughts:

* This person is very old. Do they have any documentation limiting what care we can provide?

* That looks like a hematoma, not a clear depressed skull fracture.

* I like that my fire department uses words like "depressed skull fracture", and am impressed that they're not hitting on the patient's granddaughter.

(1) I would like more information about the patient's history, and events surrounding the injury, e.g. fall vs syncope, prodrome, seizure-like activiity, pacemaker / AICD,. anticoagulation (riding the old dagatrabin train?), etc. Are there any bystanders, or obvious findings on scene?

(2) ABCDE -- Are they moving all four limbs (particularly the ride side), is there a hx of ambulation since the injury? Aniscoria? We may have to c-spine this person if our history is limited/unreliable and they're comatose. I really don't want to have to do this, especially in an octagenarian I may have to intubate.

(3) I have to ask, is it really a depressed skull fracture? Do they smell toast when I push down on it? We should probably avoid the "depressed-skull-fracture by committee" where six different providers push down on the same swollen mass and eventually decide there is a solid structure underneath that seems to be moving.

(4) I guess we should do an H&P?

(5) I'm not up on what makes a level 3 trauma center. Is this EM stafffed? Does it have a CT scanner? Presumably no neurosurg / neuroICU?

[Edit: needed a question mark, probably a couple more beer. And had questions about trauma center designations]

She is full code.

The husband reports that the pt got her feet caught on a rug around 9pm. She has a pubic rami fx from a fall 3 months ago and has times where she has a shuffling gait. Hit her head on the door but not the ground. No loss of consciousness. She went to bed at 11pm not complaining of anything. Her husband went to wake her up the next morning and she wouldn't respond. Only other history is hypertension for which she takes atenolol. Nothing unusual found on the scene other than too many FFs standing around doing nothing.

ABC as previously stated. D-no collar applied, E-no other injuries noted. She was walking around after the fall last night. Currently she will squeeze weakly with her right hand. No movement in right leg or left leg/arm. Questionable unequal pupils. FFs state the left pupil was constricted as does one of the medics on the ambulance. Other medic thinks they look equal. Palpation of the scalp demonstrates the firm swollen area, it is difficult to say with certainty if there is any underlying abnormality.

H&P normal, except for what is stated. The ER is staffed with a board certified ERDoc and a CT scanner. No seurosurg services.

is she breathing normally and supporting her airway ?

what is her pulse rate & rhythm ?

what do her pupils look like?

Any signs that this might be other than the results of a simple fall?

did anyone else witness the fall?

Unresponsive with head hemotoma gets full spinal package as they can not answer questions that would allow us to use spinal protocol to not collar & board.

a level 3 most likely does not have neuro available and may or may not have a CT or MRI available , thus she need to go to higher level facility unless she has advanced lifecare directives that state DNR or other wishes for medical care.

She is breathing and supporting her airway.

Pulse is 90s and regular

The husband and 2 other family members witnessed the fall

You are an ALS crew who is called to a house that is 5-10 min away from a small community hospital that is the equivalent of a level 3 trauma center. The call comes in as an 88y/o female, unresponsive. En route, FD on the scene tells you that they have a female with a depressed skull fx who is unresponsive and fell last night. You contact the local hospital to see if you should bring the pt there, go to the level 1 trauma center that is 45 min by ground or call for the helicopter. You are told to get to the scene and assess the pt, then make the decision from there.

You arrive on scene and find an unresponsive female who is breathing with a scalp that looks like this (only the injury was over the left parietal scalp):

Discuss.