brock8024

"He said to me the other day, he'll be behind me with whatever treatment modality I choose as long as I can produce evidence that it was in the p/t's best interest of their outcome. "

Yeah right he is lying to your face. Let something go to court because a family is suing you for something you thought was the right treatment modality what ever it was. Who cares if it was in the best interest of the patient. When he is sitting on the stand and ask if that was in protocol and says no, do you think that any jury will sit there and say well it was in the best intrest of the pt. Or if they ask him if he gave you that order or that you asked for the order do you think he will lie in court for you. Hell no. Trust me he may tell you that he'll be behind you is not total truth. Like I said if it is between your or his license, you are going to lose because he will have way to much to lose for something you thought was in the best intrest of the patient.

Brock

I have read this and some people scare me to death. I am in medic school and have been a basic and intermediate for a while. The reason I went to medic school was so I could do all the neat stuff my medic was doing. I have had the chances to do a lot of stuff out of my scope of practice, but chose not to do that.

I had a doctor tell me a very wise thing one day, and will pass it on since I have lived by it since that day.

Everyone in the medical field is your friend, be it a doctor, nurse, medic, who ever it is. You may have known them for years even, but when it comes to them losing their license or you, well you will be the one walking away with out a license.

I have lived by this for a long time. I have tons of friends in this field and trust them. The one thing I do know is that most will not stand up for you if that means they lose their house and toys and license.

So the whole point of this is wether or not he told you to do it just remember, if it ever went to court and he was going to get in trouble and he wants to save his house and things you are going to roast.

Now as far as the basic vs medic thing GET OVER IT.

Everyone is a basic first and a good basic makes a awesome medic. A lazy basic makes a lazy medic. We need basics to help out but they can be doing a lot of other basic skills while the medic is tending to the ALS stuff.

Brock

Awesome, I was looking for this the other day. I have the first two and was looking for the third.

I am with everyone else, if you use good intubation technique then you should not have to protect the teeth because the blade is going the other way.

As far as BLS using this to suction, WHY?

You are going to spend how much time putting this in then putting in the light to see the airway when you can suction without it. I personally think someone sitting around trying to make a few bucks.

I have yet to work in a urban setting except for my clinicals. I have though worked in a rural setting. There is alot of differences in the two.

This was my life in rural EMS. I worked for a hospital that had the 911 phone in the ER and Nurses station. The ER had two beds in it and if the floor had more than 5 patients then the nurse was freaking out. There was 2 emts in the hospital, 1 Rn and 1 LPN and that was it unless the doctor happen to be there. Me and my partner worked fri 7pm to mon 7am . Our unit was the only one in our area. It was bad sometimes. Like we had to help in the ER if it got busy. I know we got woken up many time to start IV's or what ever cause the nurse was lazy. Our response times was from 5 mins to 45 mins. We was instructed to bypass our ER if we thought they needed a CT or any other needs. All our ER had was lab and normal Xrays. The nearest ER that had up to date things was 30 to 40 mins away.

I think it was a good experince to have and glad I done it. I kind of like rural ems for the fact that it is usually you and your partner against the world. In urban you have fire to help.

Brock

Right now I am working in a burn center and got to see this. It was interesting to see this. From what I have read most medics could possibly pick up on this depending what stage it was in. I love this board because I think it is a great learning place with all the interesting things we learn here.

Brock

I'm probably would say that the patient is having severe side effects from the Bactrim and could be leading to Erythema Multiforme which could lead to Toxic Epidermal Necrolysis. Sounds like he is having Stevens- Johnson Syndrome right now.

Take care,

Todd

You got it he is having SJS which was caused from his Seizure med and the bactrium. Now what is the difference between the two.

When does it go from SJS to TEN

are the blisters on his feet as well?

What started first the blisters in his mouth or on his hands?

I might also want to know what kind of work this guy does and what kind of chemicals he has been using at the job site.

Blisters in his mouth started first. He is a high school english teacher.

Ok lets see the v/s are 86-90/50's, pulse in the 110's resp 12-18 and spo2 around 94%.

Pt states he had chicken poxs as a kid. He tells you the only thing different is that he was taking the new med for his SZ and started getting this rash and blisters. He went to his doctor and thought it was some type of infection and put him on bactruim.

there is some rash on his feet but not as much as the trunk and hands. The sores are in and around his mouth and he states that his food intake is a little less than normal due to the blisters. The rash areas remind you of a target or bulls eye in appearance. He also had some blisters that have ruptured during the sz and it the skin under is pink and reminds you of a 2 degree burn.

Now I have given you alot of stuff. This will more than likely give it away.

Brock

sepsis?

Nope not sepsis

Ok we need to send everyone back to basic class. If you read through this stuff no one has asked for a set of vital signs. THis can help alot plus this is kind of a though thing unless you have seen it so you might have to do some research. I do this because most of my scenarios are easy. This is a patient I got to help take care of and can be picked up by a emt or paramedic if you know what to look for.

Heck no one has even asked for V/S or anything of that nature. humm what else you want to know about this guy.

He has a fever which we know but then tells you after move questions that he has been feeling just weak all over. the rash look kind of like a target. Anythign else you want to know you got to ask for.

The rash area had different colors to it. And some areas was like blisters that had ruptured during the seizure. Hopes this helps.

This can cause this condition or be a factor but not what I was looking for.

is the rash more petechiae or purpura

Purpuric in nature

We are dispatched to a residence for an 80 year old male presenting with AMS. Arrive to find pt seated on bed, slightly disoriented. We get a brief history from his wife, stating that he had failed to turn off his alarm clock at the proper time, and he awoke in an awkward position, seeming confused. Last seen at baseline the previous night, seemed to sleep normally. History of CVD, nothing else, according to wife. We consider stroke, so we do some stroke tests, which find strong and equal hand grasp, equal smile, negative facial droop, negative slurred speech, and negative arm drift. Assessment of vitals finds bp of 130/84...pulse 68, skin warm dry and unremarkable, 12 resp/min, rales in lower left lung, SP02 93 on RA...NC on 4LPM based on o2 sats. Pupils PERL. These s/s were constant throughout transport. We didn't call ALS or transport to a stroke center due to the fact that he was requesting transport to his PCP's hospital., as he just seemed confused. He was unable to remember the year or who the president was, hwoever did answer personal questions well. Negative headache, neg chest pain, no SOB no discomfort/pain.

Would you have called ALS? Would you have transported to a stroke center?

I ask because I was told after the call by a senior EMT (i'm 17) that we made the wrong call, and I was wondering what you all thought?

From this information I would call this more than likely a ALS call. You have a 80yr male that awoke confussed. You said he was fine the night before per the wife. You said he only Hx is CVD. What is this? Cornary Vasculare Disease or Cerebral Vascular Disease. If it is the second the how can the wife say he never had a stroke but the pt said he did? You never said what meds he was on. His V/S are ok for now. The thing that would make this a ALS call for me is the fact that the guy was fine last night, awoke confused with rales in the left lung base, and he is old. I mean he could be having a AMI and not presenting in a "normal" fashion. And you said in another statement that it was a 30min transpor time. That and the other things I have stated would have made it a ALS truck. Now this is just me and I am still in paramedic school. One more semister to go, but it seems like something is going on with this guy, maybe not a stroke but something. He did not need to be ran in hot or code 3 but a 12 lead and monitor would have been nice with a IV. You also stated that if something would have happend you could have had ALS back up fast but if you are 30 mins from his hospital are there other stations along the way or another hospital.

Just my thoughts. Not saying you done anything wrong just that I might have done things different if I would have been there. That is what makes this great we all get to think for our selves.

What do you think is going on with him.

Anything eles you want to know?

What kind of workup has been done for the seizures? Let's hear a little more about the sores on his hands. Are they on his palms? Describe the rash on his chest. Any joint pains, fevers, penile discharge? What happened before the seizure?

He had a seizure at work and then wen to a neuro doctor and had a EEG. The doctor put him on his meds and has been adjusting them.

The sores on his hands are open blisters. The rash on his chest is different colors in spots. There are a few blistered areas that are open on his back and chest. He has some sores around his mouth. No joint pain, fever of 99.0 to 100 degrees. No penile discharge. Pt was sitting on couch and had a seizure per wife. The doctor told them this might happen til they get the dose of the med right. And he has had the sores on his hands for about 7 days. Went to PCP and was told it was just some type of staph infection and to take the bactrium. The rash has started a few days ago and then the blisters started yesterday. They must have ruptured during his seizure. He has a appointment with his PCP in the am per wife.

Ok you have a 48y/o M. post sz who is on the floor CAO x 4.

S/S of any trauma?

A- any allergies?

M- what medications does he take?

P- past medical history? any sz history? is he a diabetic? any heart problems? any B/P problems high or low? any respiratory problems? asthma, COPD. emphysema, any recent surgeries? any recent trauma in the last 72hrs?

L- last meal? last time to the doctor? and what for?

E O/E what do you see? any trauma ? any s/s of sz activity? How long did the pt. sz for. Any s/s of street drugs being used?

What are his vitals, Blood sugar? pupils are the e/r and what size? hand grips are they strong and equal? whats the monitor showing in lead II / ?12 lead if lead II shows anything? whats the pt/ LOC?

No s/s of trauma

NKDA

phenytoin, bactrium

Started having SZ about 3 months ago. Until then never went to the doctor.

He ate this evening with his wife

Went to the doctor about a week ago for a sores on his hands

Pt has sores on his hands, and complains of some small blisters in his mouth.

When you lift his shirt for the 12 lead you notice a few rash looking areas.

Monitor is NSR and 12 shows no changes.

FSBS is 92

pupils pearl

grips equal

Pt A&O x 4

This interesting to see how people feel about this. The two services I have worked for we transported everything unless they had all the signs of death. I know in the area I live that the paramedics at one service can call arrest at the scene but they have a protocol to go by. Pretty much the pt has to be in asytole for 30 mins of ACLS care. There has to be a ETT in place, can not be any other airway. You also have to have a IV either canula or IO. If at anytime you shock the pt they get transported. If the family wants them transported then they are. If it is out in public then they get transported. I think it works well.

As far as a baby or a kid goes, I agree with others on here. Yes emotions play a role in what we do sometimes, but if it was a termly ill kid with no DNR then I would be more likely to work them at the nursing home or at their home as long as family was ok.

I sometimes think that by transporting we give the family false hope. I mean if they see us taking them they might think oh they are getting better. Or there is another medical bill that did not need to be there. I mean we charge them for the ambulance ride and the hospital charges how much for a code, only to call it 5 mins later. And we knew that was going to happen. So sometimes we do more harm than good.

Brock

You respond to 1921 E. Main street for a 48 year old male with a new history of SZ.

Scene is safe with fire there.

Pt is in the living room floor and appears to be embarrassed.

Pt is A&O X 4

Lets see if you guys can figure this one out fast. Most of my scenarios you guys get pretty fast, so I can up with this one to see how fast it takes you guys. I made this one more challenging.

Ok so we have a 15 year old male who suddenly can not remember stuff. V/S are WNL, Neuro wise he is with normal limits but the remembering thing. Everything else seems to be normal.

We are missing something.

Ok in hospital lets order a few test.

Labs- CBC CMP UA with Drug Screen.

Xray- CT head without contrast.

EKG just to rule out

Lets see what this shows us.

Did he go to a fair or something on Long Island? I am not familar with The island but I know here in Oklahoma our state fair is in Sept.

So I am wondering if maybe he ate something there or possibly came in contact with something.

Is he sexually active at all?

I mean 15 year old boy maybe has not told his parents he has been sexually active and maybe has a STD. I know some STD's can cause neuro problems.

Just thought of something. Any cans of paint around the house. He is 15 and denies drug use maybe he does not think of huffing as a drug.

This is a tuff one, because there is nothing out of the ordinary for his daily habits. No trauma that anyone can tell. He is not running a fever or that we know of. He is drinking and eatting normal. Just all of a sudden can not remember short term things. He is just out on the soccer field and runs off to the side and then can not remember things. I am going to go with something internal is causing this.

Possible Dx's- SZ, STD, some thing he ingested, or drug gone bad.

Wow, are you an internal medicine resident??? He is the youngest of 3 kids, no suicidal ideations, immunizations UTD, does not take any supplements, no contacts or glasses, no night sweats or weight changes, no change in bowel habits. To save space, the rest of the answers are negative. We will cover skin tugor when we get to the PE.

This is from my first semister in my paramedic program. We had to do full H&P's on eachother in class and then we had to read them out loud in class. Then everyone got to say what we thought of them. The more we had to read them out loud the more indepth we got. So by the end of the semister we was able to do a full H&P on a pt and not be embrassed to ask certain questions. We ever learned how to do a indepth physical assesment from head to toe.

By the way you never said his race. Black, white?