Johnboy

I agree with fiznat 110% on this one. I, in no way, shape, or form will work outside the scope of my practice, if it means I lose my job- unless, it is for my family, and that is the only exception. We as providers did not cause this emergency to occur, nor are we sure our treatment is going to work. Someone said it before, be humble, because we only skim the surface of medicine. It is only because of the collaboration of the system as a whole, that makes modern day medicine what it is today. I am not a cowboy, nor a hero, we should be humble at the fact that we have an opportunity to learn more and more each and everyday. I commend everyone on this board for going the extra mile for their pt's, as I do the same, or atleast try. Again, my family alone are the only people on this earth that I will lose my job for. This might seem harsh, but I am not the one who jammed the 40 cigs a day into that COPD pt's mouth, nor am I the person who held down the obese person with Metabolic Syndrome down to the sofa while he stuffs another Whopper into his mouth. We all make decisions in our life, and they are the small ones that lead to a healthy, or a not healthy life. With the exception of the things we can't control, we all have a mind, to make any decision. Do your best, be humble, try hard, learn, and utilize the system to the fullest for the best intrest of your pt, but, most importantly- protect yourself, and your family- because WE COME FIRST..... JB- Dwayne- Sorry, but I am going to call you on this. I would have tried Glucagon IN. Family stated that this pt was left with deficites from the last CVA, at this point, with a BGL of 27, Stroke would not have entered my mind unless the trial of Glucagon with unsuccessful. Correction of blood sugar is diagnostic. Even if she was having a stroke, the BGL should have been correction first and foremost, also, if she was having an ischemic stroke, boluses of D 50 are associated with a worse outcome, and we unfortunately do not have a CT scanner. And if she was left with deficites, how did she return to normal? Just wondering.... JB- If you hear hooves, dont go looking for zebras...

Usal... The only thing you are going to do with hyperventilation, or even permissive hypocapnia is possibly cause a secondary brain injury by causing ischemia. Their is NO safer alternative for intubation then RSI. The ONGOING problem with ems systems is that they allow sedated assisted intubation with Versed or Etomidate only, and not a full RSI, this is not safe. Maybe someday they will allow the proper way of doing it (some systems they already do). Hyperventilation is NOT recommended, it causes only a transient decrease in ICP. Current literature states that you will get the most benefit of loweing ICP by raising the head 30 degrees, and even that may reduce cerebral perfusion . Mannitol is the drug of choice, osmotic diuresis usually taken 15 to 30 minutes, and the effect usually lasts 1 to 6 hours. JB And ETco2 levels below 30 are just outright dangerous, and is not the common practice today.

Hyperventilation is in no way what-so-ever indicated for decreasing ICP in todays medicine. It works only transiently, and has more harm then benefits to the situation. The only "safe" way to intubate wether in the field or ED is RSI. If you don't have the equipment in the field, ie, meds, and you MUST protect an airway, I would recommend premedicating with Lidocaine, and Fentanyl prior to perhaps Versed, or Etomidate (which ever you have) Lidocaine to decrease ICP (not proven) and Fentanyl (to decrease catacholamine surge during laryngoscopy, (Proven). JB

PA state has come up with a new protocol update starting statewide. Alot of good has come from this new update, however, there is a section in which ALS practitioners shall do the inital assessment on all pt's. If it is deemed BLS, the ALS practitioner can punt it to the BLS provider, providing he or she completes their own PCR documenting their pt assement. Also, the ALS practitioner shall over-see the BLS partner's PCR. Is this the begining of the end for BLS providers? I don't know many ALS providers that will take the time to do their own PCR and not ride in with the pt. Your thoughts..... JB

2R, Your pt hx is very, very general. I am assuming her back pain was lower, considering she weighs 300 lbs. Upper back pain is a whole different animal, but you did not say. You have no documentation of lung findings, or her mental status. 96% sat in a morbidly obese pt is ok in my book, if they are standing up talking to me, holding a decent conversation. Does she have COPD, you didnt say, but one would have to assume she does because of your statement about her house being filled with smoke. Again, no lung sounds were disclosed. In COPD exacerbations, you have a respiratory alkalosis in the begining from hyperventilation, (compensation) followed by a steady rising hydrogen ion concentration as they worsen, so - your statement only carries so much weight with her Etco2 being 11. I am also assuming that you have placed this pt on the litter with her feet on it as well. If she is fat, guess what, all that adipose pushes his or her lungs up into her throat, hence the decreased sat. Treat the pt not the monitor, and please before bashing a seasoned medic, make sure you have your ducks in a row. I am sure he or she cares, this seems like nothing but drama on your part. I am sure he or she knows after 20 to 30 years of experience "sick or not sick". JB

It seems like this pt is having some sort of GI bleed, of which is causing him to be anemic. This would cause his shortness of breath, as well as St segment elevations, even precipitating an MI. He is on coumadin, he is not tachy probably because of his B blockers, an his urine is dark. Would not be inclined to think that the dark urine is myoglobin, (nothing in hx to point to that). His pressure is up, most likely because he is compensating, although, his pulse pressure might be narrowing. This could be because of cardiac disease, or blood loss. One would keep an eye on his pulse pressure enroute. I would placed two lines, and give high flow 02. I would probably hold the ASA on this one, but would confer with med command just to make sure. Hope this helps.