DartmouthDave

Ok, back up is called for. You do an assessment and your findings are as follows: A - Bad teeth and dry mucus membranes with dried puke B - Rate 8-10 Shallow C- Pulse 120 and rapid and regular. Skin hot and sweaty He is uncuffed and transfer to the cot without difficulty. In fact, he is only moving his arms weakly and won't open his eyes. He is secured to the cot. A more detailed assessment shows: GCS: 7/15 (E1 V1 M5) Pupils: 2mm and non-reactive Resp: Clear Rate 8-10 SpO2= 90% CVS: BP-100/50 HR-120 (Sinus Tachycardia) Temp-39 GI: Soft GU: Incont. of urine The bottles are collected by an RCMP officer. They are two large empty bottles of 325mg ASA tabs. A bottle of MSIR 5mg tabs in a different person's name. It is empty as well. Also, a baggie that is filled with Gabepentin tabs. He was searched by the RCMP and has no weapons were found. Before he 'passed out' on the coach he was screaming in incomprehensible sounds and trying to smash stuff. Cheers Hello, The physical findings are as above. Plus the following: --> The emesis look like green bile. No blood note. Quite an impressive amount is all over the living room. No pills seen in the emesis. --> As noted above. The pill are ASA 325mg tabs, MSIR 5mg tabs, and Gabpentin 300mg tabs. Cheers

Hello, The RCMP request assistance at a downtown residence. They responded to a domestic dispute to find a 45 year-old male confused and agitated. They were concerned and requested medical assistance. On arrival you are greeted by an RCMP member. She tells that they have been here many times for domestic disputes. Recently, the wife moved out. She returned to get her stuff and found her husband to be 'scary' and 'nuts'. The wife is in the back of a police car. She was intoxicated and became disruptive and violent as well. The scene is safe. The RCMP escort you and your partner into the living room. The patient is slumped over on the coach with his eyes closed. His hands are cuffed behind his back. One of the RCMP says that he just passed out. But, just before he passed out he was breathing very fast. Around the room you see numerous empty alcohol bottles, pill bottles and pools of emesis. The room smells of stale urine, sweat, and emesis. The patient appears very flushed and his clothing is soaked in sweat. You are an ALS unit. You can call ALS or BLS backup if you wish. Cheers....

Hello, Not trying to derail a serious discussion......but what is so strange about a Druid-style wedding? Cheers

Hello, I read a fair bit and I thought it would be an interesting idea to start a thread suggesting some interesting and unique books for people to read. I am going to start off with two that have nothing to do with EMS. Here are a couple of travel/adventure type books that I like that just happen to be about A'Stan. "The Places in Between" is about a fellow that walked across A'Stan just after the Norther Alliance (with lots of help) defeated the Taliban in 2001. It has received rave reviews and is quite good. A must read I think. The Places in Between " A Short Walk in the Hindu Kush" A much older book on A'Stan written by Eric Newby in the 1950's. Back when A'Stan was a tourist destination and stable. Newby was a SBS (Special Boat Service) vet of WWII who gets tired of working in fashion after WWII and tries to climb a massive mountain with a Diplomat friend. Awesome book that is filled with wonder dry British wit. For example, "Years in the fashion industry has made me feebel." I have a 1st edition of this one complete with the receipt for a book store in NSW. A Short Walk in the Hindu Kush Here is a little more about Newby himself: Eric Newby Ok...there are tor for now. I have many more. Cheers

Ooopppps.... LOL.....I think I need to take more care when I cut and paste stuff in the future.

Hello, Hemochromatosis? I saw a liver failure secondary to hemochromatosis once. I have never seen cardiac involvement in my clinical experience yet. However, a quick look online shows that hemochromatosis can cause: * arthritis * liver disease, including an enlarged liver, cirrhosis, cancer, and liver failure * damage to the pancreas, possibly causing diabetes * heart abnormalities, such as irregular heart rhythms or congestive heart failure * impotence * early menopause * abnormal pigmentation of the skin, making it look gray or bronze * thyroid deficiency * damage to the adrenal glands Also, "Pulmonary hypertension is a problem that has been widely recognized only recently in patients with iron overload. A number of reports have involved patients with thalassemia major or thalassemia intermedia with iron overload (Aessopos, et al., 1995)" Here is a link I read: HEMOCHROMTOSIS Also, my Grandmother had it as well. It wasn't acute like this. Rather a chronic condition. Chronic management to my understanding is bleeding. You go to the lab and they pull a pile of tubes off of you and toss them. Cheers PS.... I had thought about it earlier as a cause of liver failure. But, valve issues seemed more logical. PPS... Give him Viagra!!! Just kidding. Not sure how hospital management would go. Need more time to think about it.

Hello, Yes, there should be room for discretion. However, this is slippery slope. From the EMS side some people do not transport because they are slacking. I have seen some bad calls in regard to non-transport. As for the ED attitude. Most ED that I have worked in are gong shows. You are up to your eye balls in patients ranging from the lame to the very ill. So, anybody who brings more patients may get attitude. Personally, these attitude stems from work load issue in the ED and EMS sometimes takes the flack for it. Along with the wards, ICU and detox et al....... Cheers

Hello, Thank you for a well presented scenario. This fellow has a long standing history of fatigue that has worsen over the past six months. The most notable recent changes are: • Elevated JVD • Icterus • Edemous feet • SOBOE • Massive Mummur • Bleeding of the gums • Bruises • Hepatojugular reflux Add to this clubbing. This means this fellow has had a long standing tissue hypoxia. Now, this is my weak area so bear with me here. I have very little experience with CV Surgical ICU type of stuff. To me is it sounds like a long standing valve issues that has worsened. As opposed to liver failure causing the fluid over load that has stress his incompetent valves. I have seen a few non-alcoholic liver failure patients present like this (NASH). But, none had a long standing history of fatigue, clubbing and weakness. Most had decreased LOC due to ammonia levels. So....time to make a Dx. What is the immediate field diagnosis? Since the physical finding lean towards righted sided diastolic failure I am going to go with an incompetent tricuspid or pulmonary valve. What is the underlying pathology and what is the pathogenesis of the recent decline in his condition? The pathogenesis could be worsening of a murmur he has had all his life. The right sided failure is causing hepatic congestion and the signs of liver failure. What is the field treatment, and what is the definitive treatment? Field treatment should be supportive care. IV, O2 and VS. Definitive treatment will depend. In the ED this fellow would get CBC, INR, PTT, LFT to start. HIV and HEP serology. Ammonia level. ABG. A CXR and a quick look with an ultra sound. The EP would call Internal Medicine to sort it out. Prognosis? Good. I have seen bigger wrecks walk out the hospital. Also, he is young without a bad medical history or bad habits. Cheers

Hello, Thermometer. Temps are not done often in the field. Not a sexy piece of kit but useful. Cheers

Hello Herbie1, Maybe the lasix......If he took too much. Weak I know. I have seen it only with IV Lasix. Here are a few examples I have seen: Lasix - In higher doses and if give IV push too fast can cause tinnitus. Saw this in a lady who was getting 80mg IV BID in the ICU setting. Lidocaine Infusion - The patient c/o horrible ringing in his ears Bupivacaine/Fentanyl Epidural - It was inserted by the DR and a loading dose of Bupivacaine (much higher concentration that the epidural) was giving. The fellow had tinnitus for the next 36 hours. Various Abx as well.......Vancomycin I think. Just felt like typing a big unrelated FYI............ Cheers

Hello, I agree. I have seen quite a few DKA that have had a serious secondary issue as the cause. Also, from most protocols that I have seen and used it seems that the BGL was lower a little too fast (37--->12..in 3 hours). IMHO. The HTN is quite odd as well. Cheers....

Hello, Man.....I missed the BLG in the first post! My bad.

Hello Andy, I agree with HellBells. Go to a public school. For example NAIT. Private schools are a business. Therefore, profit driven and the owners have more 'freedoms' if you will as to how they treat students and what they do to students. Good or bad. A public school, like NAIT, has rules, regulations and standards. Plus, clinical sites. Lastly, transcripts. An actually college (...just isn't using the word 'college'...) will have them. So, years from now their is a record of what you have done. An academic record that can be sent to other colleges and universities that you may want to attend. Heck, I knew people who went to Lifeskills Risk & Rescue in Banff/Canmore. Their only proof of an actual education is a cheap certificate printed on a crap computer printer. Go to a publicly funded and accredited school. IMHO.

Could be Double Whammy Syndrome: Double Whammy Syndrome No.....just kidding. =) My experience with babies is quite limited. So, I am venturing into unknown territory here. The infant was seen in the morning in a ED and had a fever and seizure. Ok....nothing too alarming there. Now, a few hours later `bug eye` and abnormal eye movement. Maybe the mother or the boyfriend (or both) got overwhelmed by the fussy baby and shook the little guy? Shaken Baby Syndrome? It is my understanding that SBS infants can appear quite normal in most regards. • Bulging eye = Elevated ICP • Abnormal Breathing Patterns = ICP Interested in seeing what the outcome was in this one.

Hello, Don't you just give Narcan to every altered LOC? Cheers

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?

Hello, Also TCRIPP I see that you are in Texas. The SLAM airway course is in the Dallas area. They have a cadaver lab as well (...or when I took it in 2007...). There were ACP, RN, RT and DR on the course. There were a few complaints from some medics that it didn't focus on the 'street' enough. However, I think they has made up their mind before the course started. In reality, it was a nice mix of hospital, pre-hospital and different professions I found. Cheers

Hello, The Difficult Airway textbook has excellent information. It can be a bit of a dry read but quite useful. The depth of information is very good and I think more in depth than what is covered in most Paramedic programs. Plus, one of the authors (Dr. Murphy) understands EMS very well and if I remember correctly helped develop Emergency Health Services Nova Scotia (EHS NS). Thereby, elevating EMS in the province out of the stone ages and in to an award winning organization. Looks like a new addition as well. Difficult Airway Text An other good book is James Rich's SLAM airway textbook. Covers a huge range of airway management information as well as RSI. Reading wise the writing style is 'lighter' than the Difficult Airway text. SLAM Airway Text I hope this helps. Also, as you read up on the subject feel free to start threads on topics you want to discuss or need assistance on. Brain gym is always a good idea. Both can be ordered online. Also, check your school's library. They may have a copy as well (easier on the budget). Cheers.....

Hello, Sepsis could be an option as well. Renal transplants are high risk due to the immunosuppression medications (i.e. Tacrolimus, ect...) they need to take. MI and cardiogenic shock is high on the list as well. Acidosis from the renal failure. A whole pile of problems here. I think the resp failure (SpO2 of 80%) is a perfusion issue as well. Holding the ASA was a good idea. -->Just wondering. How did you know the INR was 6.5? -->Was this patient on Warfarin for the Afib?? (INR 2-3 is goal for Afib) That may account for the elevated INR. -->What is this lady colour? Eyes? Jaundice? Liver issues can also account for the INR. Just wonder how things worked out for you. Any follow up from the ED? Cheers...

Hello, DH, I agree that 12-lead EKG are an important part of any progressive EMS system. STEMI alerts. Baseline EKG. ACS care starts upon arrival of EMS. Wonderful stuff. However, FL Medic position has validity as well. There is a great deal more to 12-leads than what is covered academically for paramedics (other medical professionals as well) or seen clinically by medics in the field on a regular basis. This 12 year-old falls in to this category. I am sure when the EP arrives they will be calling in or talking to an expert on this one. One last thing. What is AMS..... Pupils equal/reactive? H/A? Tinnitus? Blurred vision? Paresthesia? Nice.......thinking about EKG changes due to a SAH..... Cheers...

Hello, 1. BGL = 545 mg/dl (30 mmol so so I think) Dose she take insulin or is her DM controlled with medications? - Voided twice in last hour - Laying on a urine stain - Looks like DKA or maybe Hyperosmolar Syndrome 2. Renal - On the floor 24 hours or so - Weak left arm - Rhabdomyolysis could be a possibility as well 3. CVA - HTN+++ - Droop and left arm deficit - Million dollar question.....is it old or new?? - Do we see any aid of daily living to help her with her weak arm? That would make me lean towards an old CVA - Good LOC.... Again, may be an old CVA...not sure I like Kiwimedic idea...a 12-lead. Who knows what this lady K is. Maybe, get the friend to help you out. She may be able to get her to go to the ED. How safe is this lady? Once off the floor can she actually move around and take care of herself? Also, can the friend give more information about the patient? (i.e. the arm and droop) Besides, what ED wouldn't want a 375lbs women in poor health?? Easy to fix and easy to discharge...... =) Cheers...

Hello, I like Jonas Salk questions: What dose the kid look like? Tall, thin --> Marfan Syndrome ?Disection? What is his ethnic background? Balck --> Sicke Cell Crisis?? I would ask the father: -->Any distant medical history when he was younger? Kawasaki Disease? (I only ask because there was a child in the ED awhile back that had cardiac issues due to childhood KD) -->Any auto-immune diseases? -->Any SCD in the family? I would ask the patient: -->PO Intake; any energy drinks? I would reassess the patient and look for: -->Any rashes? Also, I would crack a CPS. And look up ADHD med......I am not family with it. Any dose changes? Labs and Investigation: I CXR would be nice. So, I guess we have to wait for the tech or the Dr. Lab.....I would go with CBC, Lytes, Tn, Urine + Serum Tox and BUN/Cr At a bit of a loss. Ped Cardiac isn't my strong point. Cheers

Hello, 100% on the money ---> Hyperventilation Crisis Sorry about the first post. Sometimes it is hard to describe a complex presentation in words. Again, correct on the second point. No medication here that would cause a Dystonic Reaction. Further assessment.....I was think about an obstetrical assessment. Station. Position. Was an u/s done? Stuff like that. Cheers....