AT-Medic

tskstorm: Are you in EMS long enough to remember the Federal "Q" siren? Loudest vehicle mounted electrical/mechanical siren I know of, and actually needed a brake to stop it. I had one on my first ambulance, itself a Caddylance.

I love the Q brake, sounds like something from an old movie. Kinda funny when used at just the right time. Federal Q sure got it right.

In answer to Public Enemy's "9-1-1 is a Joke", a few members of NYC HHC EMS created this one, as an answer. It dates to the "Green and White" days, and I no longer remember names, but at least one of my EMS Academy (Nurses Residence Building at Queens General) classmates (NEOP 85-02) appears in it.

http://www.bing.com/...f45-58684014747

Keep it safe, and I hope to see you in LIC in June, Farooq.

Not really my style of music, but I did like it. Thanks for posting it!

Tell him that unless you know he has taken vitals, you will not sign the run sheet.

Do them yourself. After you load the PT, grab the BP cuff and ears and obtain the V/S. The guy will either be guilted into it while working with you or you simply do them yourself. Do NOT trust someone who is this blatant about poor patient care.

Years ago when I was on the privates, we were supposed to take a patient out of an ICU to go to another hospital. No special meds or drips, but it was someone with a very sick heart. We asked the nurse what the vitals were and she said- stable, normotensive. We looked at the guy and he LOOKED like he was ready to code. I told my partner to manually check his BP and it was 60 systolic. I told the nurse this guy was NOT stable and asked if they were going to do anything about the BP. She checked with the resident and he blew it off- "Just transport him". I said I was not comfortable with that BP and called our medical control. We were instructed NOT to take the patient. Of course the doc and nurse had a hissy fit, we put them on the phone with our doc, and the resident looked really sheepish. He hung up the phone and directed a tirade at us. We ignored the guy and walked away, expecting to catch hell from our bosses because we pissed off one of our big accounts. I told the boss the story and surprisingly, he backed us up.

It's your license to lose. Protect it and your livelyhood.

Very good advice, and an excellent post. Way to stand your ground and do the right thing for the ICU pt, inspite of being pushed by the resident MD and the nurse!

So far I've got a, "Why did you bring him here for that?", from a knocked up nurse who didn't want to be at work today. I begged her forgiveness and stated that I was not allowed to refuse a requested transport. She replied with a roll of the eyes, and stated, "well what am I suppose to do for him?". I had a whole host of replies run through my head, but I smiled wishing her a nice day and returned to my short bus with flashy lights.

One of the local ER's put out some stuff, but I didn't make it there yet. I'm sure it was picked over very well by now, lol! Hope everyone has a safe EMS week, well a safe week every week for that matter.

AT ,

I couldn't help but note that you stated Wikipedia as a sourece of factual information...........Sorry dude. FAIL.

I still disagree.....

OMG - did I fail, LMAO!

You sir are hilarious.....

I would personally use our Medication Assisted Intubation (as we are not allowed to use Sux in our system). This is basically drowning our patient with etomidate. So, 0.3 mg/kg of etomidate please. Boujie tube if necessary.

If the patient is still clencked, re-oxygenate and nasal intubation.

When we get the tube in Fent and versed for continued sedation......

Hello,

Fellow pulls over (no erratic driving...crashing into stuff, ect...)his car and suddenly becomes unresponsive (if I am following this correctly so far).

So, a sudden onset of neurological decline with very high blood pressure and pinpoint pupils. I am thinking a Pontine SAH. Add to this a seizure and crackles in the patient's lungs (Neurogenic Pulmonary Edema). Yep, could be a SAH.

Kiwi stated:

"12 lead shows anterolateral infarct (couldn't be buggered searching for a copy we know what it looks like)"

Now, do you mean ST elevations? If so, sometimes SAH cause ST elevations in various leads. Also, sometimes pump failure rapidly ensues from a 'stunned myocardium' in SAH patients. Sorry, no references, but I worked in a Neurosurgical ICU and these were fairly frequently complications of a SAH. Too late to go digging for a reference.

As a DDx:

1. Hypoglycemia

2. Effexor OD

A BGL of 4 mmol isn't so low. I agree with ArmyMedic that giving glucose to a possible CVA isn't a wonderful idea. However, I would give 1/2 and amp of D50W as soon as the IV was in (while getting airway and other stuff set up).

I have seen many people try to OD on SSRI. Nothing much ever happens. With Effexor being a SNRI I have seen lots of troubles. But, in general, I haven't seen seizures or pinpoint pupils. Seizures seem to be much more of an issue with Effexor OD from my experience.

Key right now I think is treating the seizures and securing the airway.

Cheers...

PS... Give Narcan?

Excellent post. You are working the same approach as I think I would be. Treat for seizures due to possible OD, rule out CVA, work with the good airway we have, and secure it via ET time permitting. Depending on what station I’m working at, I could be just a block from the hospital, or be 45 plus minutes away. So it changes how you do things completely.

In 2008 I became certified as a 40-hour first responder at the age of 15. The local health services agency provided the training as a summer boredom buster. Since then I've assisted several indivduals who were experiencing medical emergencies ranging from fainting to a scalp laceration. But here's the catch: our state does not recognize first responders. No protocol for FRs exists within the state. It wasn't until several months ago that I realized this. I've mentioned it to the local EMS and even to the hospital, but they don't seem to see it as a real issue. I'm familiar with FR protocol from other states, but I have no clue as to what I can and can't do in my state. I don't know what I can and can't carry in my jump kit (which was given to me by the instructors for scoring 100% on the final exam). When it was given to me it had activated charcoal and glucose. I know some states allow their FRs to use those two items, but I'm not sure if I can. But the whole point of my post here is to ask some of the experienced EMS people about what types of issues might arise from this issue, and any possible solutions. Thanks

I agree with kiwimedic on this one. Take time to go to the next level, and don't fall victim to an endless liability issue.

I like your thought process wit hseizure, but disagree with Hypertension as hypotension is the side effect of choice with effexor.

Funny..... Although, kiwi already clarified this....heart rate and pulse rate are not the same and can be different. One measures the electrical rate of the heart (HR), as the other measures its mechanical manifestation (PR). But that is a discussion for another thread.

AT, I must disagree. Although intubating based off of the patients GCS score would be considered bad form where I am from, I agree with Ruff as airway control is key. An unresponsive patient cannot definitevely control his/her airway (especially as presenting for this scenario), therefore CPAP/BiPAP would be countra-indicated in this case. if RSI is not in your bag of tricks, nasal intubation might be the ticket.

Based on the airway values given in the very first posting, I'm not going to knock an emt out of the way to get too my ET kit. Which was my whole point to start with, rushing to intubate is not the key. ACLS is pushing basic airway management over advanced management, and I agree. I also indicated in my post that a change in airway status would cause me to intubate. I myself would not place the pt on CPAP based on the first post. I was indicating that the ED Doc might place the pt on BiPAP, which I have seen done to pt's I thought should be RSI'ed, but I'm a P and not an MD so I follow orders and ask questions to better understand the line of thinking afterwards. I think I saw in another post where the pt's status is changing, so this fellow is buying a tube. Ruff missed the point of my post and got all Ruff'ed, LOL! The pt is a work in progress, as most all pts are. I had a feeling that the pt status would change as post came rolling in, and it has.

Phil, I dig your style, but why the glucose? If the patients Blood sugar is 90 mg/dl (~4mmol/l). I would not consider that hypoglycemic, and as we cannot determine whether a stroke type event is hemorrhagic vs embolus. I would be extremely cautious with this. However, if I have misunderstood, please clarifiy for me...please.

Another reason to control this patients airway.

I like your thought process wit hseizure, but disagree with Hypertension as hypotension is the side effect of choice with effexor.

You should direct yourself to the following sources of information; Epocrates, medicinenet, and wikipedia. The side effects are a mile long list that could fit any pt.

Funny..... Although, kiwi already clarified this....heart rate and pulse rate are not the same and can be different. One measures the electrical rate of the heart (HR), as the other measures its mechanical manifestation (PR). But that is a discussion for another thread.

AT, I must disagree. Although intubating based off of the patients GCS score would be considered bad form where I am from, I agree with Ruff as airway control is key. An unresponsive patient cannot definitevely control his/her airway (especially as presenting for this scenario), therefore CPAP/BiPAP would be countra-indicated in this case. if RSI is not in your bag of tricks, nasal intubation might be the ticket.

Phil, I dig your style, but why the glucose? If the patients Blood sugar is 90 mg/dl (~4mmol/l). I would not consider that hypoglycemic, and as we cannot determine whether a stroke type event is hemorrhagic vs embolus. I would be extremely cautious with this. However, if I have misunderstood, please clarifiy for me...please.

Another reason to control this patients airway.

Well AT, It's really good that you have bipap but for those of us who do not have bipap, cpap, epap and whatever brand spanking shiny things that your service seems to have Intubation is my only tool. RSI I do have.

I've been involved in Effexor overdoses before and they can get bad really quick.

I did not go on his Glasgow, I went on the thought that he overdosed as well as was unconscious. I did mention bagging him, perhaps I should have said, let's see how bagging works but I have one hospital to send a patient to and the physicians want them intubated. If I were to fly him, the flight crew would have immediately intubated him if he remained in that state.

So to bash me was not a good thing. You have more tricks in your arsenal and I have less. So be it.

We have cpap but it's in a freakin closet because they haven't written the protocol for it. How's that for backwards.

Before you slam other providers with their treatment you might want to get some clarification as to what we have to work with before you go off and make yourself look like a A***

So KIWI how many pills are missing or do they seem to be all there

What are the pupils? Be it a overdose or a Stroke, unresponsive means BAD MOJO

Wow, name calling. After a slight review of my post, I find that in no way was anyone being slammed, so get over it, and go un-Ruff yourself...LMFAO!

Ok we've got the basic vitals. What is critically important for this guy is airway control. Get him intubated with that GCS. Once that is done we can get the IV and all that jazz. You could bag the guy until you get the IV in case you need to RSI him. He might not tolerate the intubation so we can RSI him.

Do a repeat Dstick with the IV needle blood.

Check pupils and then load and go.

Wow, that whole below 8 - must intubate mind set. Hence the reason for all the studies out there wanting to take intubation away from us. Its not your first tool in this case, or in about 99% of all cases. In reviewing my post, I could have added to my Local tx statment, the fact that I would have used an NPA, and placed the pt on 02 at 15-lpm. This pt automatically buys a 12 lead, which was something else I left out. I would also monitor his EtCO2, which would have some bearing on intubation. Unless there was a staus change with the airway, bagging would have been the most I would have done. The ED would most likely place this person on Bi-Pap, not intubate, but then again, you sometimes can't guess what the Doc is going to do.

I don't want to go into treatment as that can be as different as night and day depending on location. So I'll take a shoot as to what I think might be the problem. Effexor is a very popular drug for depressive disorders in general. Effexor also comes with a nearly never ending list of side effects. I would highly suspect a toxic response to the Effexor as a result of OD or hypersensitivity. The pill bottle will yeld information as to when this Rx or refill was started, dose, and by counting - the number of pills left, assuming that there are no pills in a plastic pill box at home. So based on the current vitals, I woulld guess that the pt is in a postictal state from a seizure caused by the Effexor, as well as the fact that the pt is hypertensive and tachycardic which are both side effects of Effexor. Whats burning in the back of my mind? Is this an intentional or unintentional OD? Although decreased in this pt's age group, the risk of suicidality is high on Effexor.

Local tx for this pt would be; support ABC's as needed, monitor for change in status, moniotr heart rhythm, IV-kvo or saline loc, transport to hosp. I would like to address the HTN, but there is no HTN tx in Maryland.