usmc_chris

Hello, Posting the follow up now. He was transported to the Level III trauma / PCI center. My system places great emphasis on customer service / destination requests, the transport time difference between the two facilities was minimal, and the facility he was transported to should have been able to handle the patient's condition. The final ECG printed as he was taken into the ER is attached. Upon arrival at the hospital RSI is performed, pressors are finally successfully hung, and the patient is sent to CT. Cerebral hemorrhage and cervical spinal compromise are ruled out with CT. After about 90 minutes in the ER he is finally sent to the cath lab. They identified a 100% proximal LAD occlusion but were unable to open the occlusion prior to the patient going into cardiac arrest. Unfortunately he was not able to be resuscitated. I posted this case for a couple reasons: 1) Neither myself or any of my coworkers had ever seen ST elevation as severe as this patient had in the anterior leads, and I thought it would be interesting to share it. 2) I learned some things here, and wanted to continue to learn from this case. First, I may be beating myself up, but I feel I was a little too complacent on this case. We respond to a lot of "done fell out" at church on Sunday and what I was presented with was absolutely NOT what I was expecting. I wish I had brought more "stuff" to the patient's side, and I wish I had been more proactive with obtaining additional help in the back. Our first responders are normally good about riding in with us, but I honestly had no idea where they went once we got into the ambulance. In addition, given that it was "off" / weekend hours, the Level I may have been more promptly equipped than the facility he was transported to. Obviously, hindsight is 20/20, but the day we stop learning is the day we need to get off the truck. http://www.emtcity.com/gallery/image/894-/

Gag reflex intact. You are able to assist ventilations; his SpO2 returns to normal. You now arrive at the hospital.

You were unable to get the Levophed flowing prior to the seizure (crappy roads). Midazolam is administered (he received 2.5mg IVP) Heart rate is in the 80's again, pulses still present however breathing is now ineffective post-midazolam. You're about 2 minutes out.

Two short strips are attached. http://www.emtcity.com/gallery/image/892-/

At this point the patient is unable to provide any additional history. The patient and his family indicated that his only known medical history was hypertension. Anything is possible, but nothing else is suspected in his history.

You're about 4 minutes out. His heart rate returns to about 86bpm and he starts seizing again.

Exactly. They won't send him to the cath lab until they have ruled out intracranial hemorrhage. Meanwhile, as you're mixing up your drip the patients pulse rate drops to about 40. It still appears to be sinus in nature, however QRS complexes are beginning to widen. He still has a weak but palpable carotid pulse corresponding to the monitor. His Mentation also declines, he becomes nonverbal and withdraws to painful stimuli.

You normally carry Dopamine however due to shortages you have Levophed today. I suppose Epinephrine could theoretically be an option with online consult but it's not in your protocols. Only history is HTN, no previous cardiac issues.

You place pads and tell your partner to head to the hospital. You glance out the door to take some help and the big red truck has disappeared - you're on your own. 500cc bolus is given with no improvement. Pt is placed on supplemental O2 and noninvasive ETCO2 monitoring. Lung sounds clear. You are having difficulty auscultating heart tones over the road noise. Mentation remails about the same. Mom is left behind and the patient isn't arguing about destination. Latest vital signs: BP 64/40 P 90 sinus w/ PVC's R 36 / irregular ETCO2 30 mmHg SpO2 94% on 4L via NC Cath lab is activated as is trauma team. You are 10-12 minutes out, is there anything else we'd like to do for this patient?

The dizziness began during the service, towards the end, no more than 20 minutes before the collapse, however became much worse when attempting to walk outside, precipitating his collapse. He has otherwise been healthy with no recent illness. He is normally lucid with clear speech, however currently is speaking very softly and slowly, but is aware he is in the ambulance and that he was at church. He also knows his name, date of birth, and that is Sunday. He is very sleepy and but responsive to verbal stimuli, and will wake when you call his name. This was approximate mental status during the interim between the collapse and the seizure. Your response time from the initial 911 call for a "fall" was approximately 7 minutes. The seizure began almost immediately as you arrived on scene, prior to making patient contact. This was his first seizure, and he has no known seizure disorder, and has never had a seizure before in his life. The last thing he remembers is walking out of church, does not remember falling and does not remember your arrival or being moved to the ambulance. The dizziness is mostly described as feeling as if he is going to pass out again. Approximate depth of respiration is shallow but equal, and they are irregular however no noted episodes of apnea. Further physical exam is essentially unremarkable, no noted obvious external manifestations of head trauma or to the rest of the body. Breath sounds are clear/equal bilaterally, pt is moving air with no noted wheezing/rales/rhonchi. Pt is soft-spoken but not apparently slurring his speech, no noted unilateral deficits and no noted facial drooping. Mom is very insistent that he go to the Level III, they "don't like" that other hospital. You acquire the 12-lead. It is attached. http://www.emtcity.com/gallery/image/891-ecg1/

Pt is stripped to the waist, placed in a c-collar, and full spinal precautions are taken. During this you manage to place one 16ga IV, saline lock, in the pt's right AC. Pt is subsequently moved to the ambulance. Pt is now conscious but remains lethargic, is responsive to verbal stimuli but seems to be oriented. Pt c/o dizziness but denies other complaints including chest discomfort or shortness of breath. GCS - 14 (3/5/6) BP - 72/54 P - 100 R - 32 / irregular and shallow SpO2 - 90% RA You place the patient on the cardiac monitor. Rhythm shows a regular sinus rhythm with a rate of 100-110, however multiform PVC's are also noted at a rate of 10-15 per minute. Pt still has a palpable radial pulse, corresponding to the rhythm displayed on the monitor however it is extremely weak. Pt remains profoundly diaphoretic.

And now to bring the thread back on topic. Sorry it took me so long to respond; I was in the field for drill weekend (and I thought the stupid thing would email me if there were any replies) You grab your equipment and approach the patient on the side walk. As you approach, you notice that the fire department (BLS first response) has arrived but are standing around the patient with confused looks on their faces, looking to you for instruction, and nothing has yet been done. The patient's mother is at his side, generally in the way, yelling at you to do something and that she's a nurse. You are able to obtain a more accurate history from her, she states that as they left the service the patient stated he was dizzy then suddenly collapsed. She states that his only known medical history is hypertension, he takes Lisinopril 10mg once a day, and he has no known allergies. He fell backwards from standing and struck his head on the sidewalk. As you are able to clear enough of the crowd to see the patient, you discover that he is actively seizing, and is profoundly diaphoretic. The seizure ends (duration approximately 90 seconds) as you kneel at his side. Rapid trauma assessment is unremarkable for gross deformity or bleeding however the patient is severely post-ictal and unable to verbalize any complaints or responses to palpation / physical exam at this time. Pupils are approximately 6mm and sluggish but reactive. Peripheral pulses are rapid, extremely weak, and thready. You instruct the first responders to obtain vital signs, however they are unable to auscultate a blood pressure. BSL is 116 mg/dl. You (I) am an idiot and left the monitor in truck, about 15 feet away. What is your next course of action?

Hello, I haven't posted in a while, but I have an interesting case to run through the scenarios forums. So here goes. You work for a busy urban service. You are working on a Medic/EMT truck. At approximately 12:30pm you are dispatched with the fire department BLS first response for a report of a 40 y/o male c/o dizziness who has fallen at church. While enroute the call is re-coded as a syncope/unconscious instead of a fall, but no further information is provided by dispatch. Your scenario begins as you arrive on scene, you arrive within approximately 6 minutes of the initial dispatch. The weather is fair and sunny, around 60 degrees Fahrenheit. You see a crowd, including your fire department first responders, gathered around an approximately 40 y/o black male who is lying supine on the sidewalk outside of church. Your two closest facilities are a Level I trauma center, with the full range of services, and a Level III trauma center which has PCI capabilities and off-site neurosurgical capabilities at a sister hospital about 5-6 miles further down the road. Both facilities are an approximately 10-15 minute transport from your current location, depending on traffic conditions. What would you like to know / do?

2 things I'd really like to know before giving ANY pharmaceutical or electrical treatment, unless the pt is decompensating rapidly - BG and what he 12-lead looks like. Your partner can hook up the 12-lead while you go for the line. Is there any history of renal failure or diabetes? When you factor in the possibility of electrolyte imbalances, especially hyperkalemia, I've seen sinus tachycardia that looked an awful lot like VT in one lead only - the P wave unidentifiable in the downslope of the T wave in an isolated lead.

Well Ruff, this is going to stir up some controversy, but by the court's "disparate impact" argument, it absolutely is racist. If it weren't racist, why would only 23% of the employees be white? I don't agree with that one bit, but that is EXACTLY the argument the Chicago FD people are using, just the "color composition" is reversed.

Yes, understand, I forgot that that the OP specified it was a nurse in the ER. I agree, in some circumstances, it may have been warranted, but I wasn't there either To the OP: do you know any more about the scenario? Any more details about the pt and her overall condition? Thanks!

I agree, he did cross the line here. As the article said, it was part of a closed group run by the department Deputy Chief. While the article doesn't specifically say it, that suggests that most, if not all, of the members of this group were employees of the Department. Based on that assumption, it shouldn't matter from where the comments were actually posted... they were effectively said in a work environment. Had the comments been just posted generically on his main Facebook page, that MAY have been a different situation. To me, however, based on the venue, it's pretty clear that 1st amendment protections don't apply. As for the argument about the 1st amendment only being applicable to infringement from Congress, the 14th Amendment extends the protections of the 1st amendment to the various States, and the courts have generally held that by extension they also apply to local governments. I'm not exactly a Constitutional scholar, but I would presume that to mean that a Fire Department, as a government agency, couldn't infringe on those rights, provided the comments were in a non-work venue. That being said, I agree with most on here that this would constitute a work venue and therefore his speech is and should be subject to restriction.

I don't believe I've ever shocked a fully "alert" patient. Most patients who need immediate cardioversion are going to show it - they probably won't be sitting up, chatting about the weather etc. - rather, they'll have unstable vitals, be short of breath diaphoretic, etc. While it is true that this lady probably wouldn't have stayed up and cheerful for very long while in VT, I would imagine there would be time to premedicate. In an adult, average weight pt I will usually use 5mg Morphine and 2.5mg Versed IVP, assuming no allergies or other contraindications. The really neat thing about the Versed is it has some short-term amnesic properties, so if you give it and cardiovert within a couple of minutes, the pt will probably forget what you did to them, except for wonder why their chest hurts a little (and that's where the Morphine helps!). Based on the condition you describe the pt, I see no valid reason to not to medicate the pt prior to cardioversion. Shocking a conscious patient [without meds on board], unless they REALLY, REALLY need it RIGHT NOW, is just plain mean, IMHO. Of course, I wasn't there, so probably shouldn't pass judgement without knowing more about the situation.

Not to be off-topic, but you CAN'T join the Marines and be a combat medic. We don't have them. Which is why, after 6 years in the Marine Corps Reserve, I'm working on re-enlisting in the Navy Reserve, in order to become a Corpsman, in order to transfer back to work with the Marines as a combat medic. Figures I should do the same thing in the military I do in the civilian world. As to the topic, I too, believe that ACLS could be more in-depth. The first time I took it, I was an EMT-B. I scored 100% on the exam. Of course, I had no freakin' clue as to what the WHY was for any of the treatments, which is something, I think, that is much more important than the WHAT.

I missed this question, sorry. It was on the left side of his neck.

I don't know about everybody else, but I've NEVER had a problem shaving anybody, for defibrillation or for 12-Lead acquisition, with the 15 cent, single bladed disposable razor that my company provides us in our monitors. Sure, you need to knock the hair out every few strokes (swiping it backwards across a towel, or the pt's shirt, or the carpet, or whatever, works well for this), but they're quite effective, in my opinion.

Sorry it's been a while, I'm in Bridgeport, CA at the Marine Corps Mountain Warfare Training Center for my 2 week Annual Training for the Reserves, with limited internet access. It wasn't actually his ear. No recent scuba diving. It turned out that he dissected his left carotid artery. When we picked him up it was a small hole, but it could have easily turned into a much bigger hole and bigger problem. Overall a very interesting case.

Fair enough about the possibility of a mechanism, however he more than meets our "selective immobilization protocol." Of course, there's people I don't board that technically don't meet the "letter" of the protocol, but after all they're guidelines, right? At least that's what the preface to ours says. We make the best clinical decision we can based on risk/benefit we can for each individual patient. I completely agree with you on hating long boards though. While I didn't see his lab values, based on the final diagnosis, I think it is safe to assume that his electrolytes were relatively normal. The "pop" is the key to the final diagnosis (well, various tests were used to confirm it, but in hindsight, from a pre-hospital perspective, it's all we have). It is in fact what started everything. And it isn't his inner ear. Any other ideas?

Well, I'll give a few hints. I'll tell everybody what it's not. Its not a cardiac event, and it's not an anxiety attack. It is not a c-spine problem, in the actual call I didn't even think of immobilizing for a few reasons. One, I'm a big fan of NOT backboarding people, because of some of the literature I've been reading about worse outcomes following immobilization. Also, there was a lack of any kind of mechanism. Finally, we didn't get the story about the "pop" in his neck until well on the way to the hospital. We also did not treat the nausea as vomiting wasn't imminent. Also, we only carry Promethazine, and I didn't really want to sedate him anymore than he already was from being generally lethargic. We did call ahead to let them know what was going on, in that we had absolutely no freaking clue what was going on but he had that "pre-code-looking" look to him. So, vitals remain "stable" through the transport. You bypass the triage line based on your prearrival report, going directly to a room. At this point, he is starting to be a little weaker on the left side, however no facial droop, no slurred speech. The ED doc meets you at the room and is initially thinking of an atypical CVA presentation. He allows you to follow him and the pt to CT, as as soon as a 3rd IV is placed and labs/cultures drawn, off he goes, he's only in the room for about 5 minutes. Head CT w/o contrast is unremarkable, head and neck CT w/ contrast shows nothing per the ED doc and the radiologist brought in to assess the CT. So, what else might it be? Any ideas? And don't feel bad Dwayne, my partner and I had no clue whatsoever what was going on either. I only know because we followed up about 2 hours later with the hospital. Not telling yet though!

Vitals Oxygen Monitor I.V. Transport