DartmouthDave
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Posts posted by DartmouthDave
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Hello,
Here is an interesting patient from a couple of nights ago that came through the ED.
You are dispatched for an 18 year-old female patient who has had a seizure. On arrival the Paramedics find her postictal. Her eyes are open, she is moving all extremities and is moaning in pain. She is drowsy but know who she is but can not remember the seizure.
Her airway and breathing are fine. She is incontinent of urine (...her pants are wet...). However, the urine stain appears to be bloody (gross heaturia).
She is from out of town visiting her Aunt. Her Aunt tells the crew that she had a seizure yesterday. But, it wasn't this bad. Also, she says that she has a rare renal condition know as 'Loin-Pain-Hematuria Syndrome' (LPHS). She has a small folder filled with information on the condition for the crew to read. =)
Here is the easy version:
The Aunt says that since arriving the patient's flank pain has been poorly controlled with Demerol pills. She has had to take more than normal. Also, she states that the patient is unable to attend school now due to her illness. In fact, the patient has been depressed as of late.
Her only medications are Demerol 100mg PO for pain and Immovaine 7.5mg QHS.
A head-to-toe reveals an healthy looking 18 year-old female (50kg) with a few old IV sites on her hands and arms. Her Aunt states that they are from old IV that she had done in her home town hospital for pain.
BP 140/92 HR 130 SPO2 98% Temp 37.5 BGL 6.7
So, what is causing these seizures? What now?
Cheers....
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I'm definitely thinking ACS on this one. If there is ST segment depression in V1, V2, and V3, but no ST elevation on the 12-lead, I would get V7, V8, and V9 into the mix for a 15-lead. Sounds like a posterior MI. Standard ACS treatment... 15lpm O2 NRB, IV access NSS KVO, 12-lead, 15-lead, ASA, nitro, morphine, draw labs if I'm in a system that lets me do so, rapid transport to the closest appropriate facility (preferably one with interventional cardiology).
As for the fixed wing aircraft stuff, I don't have any critical care experience so I'm not even going to touch that one.
Hello,
Nice call on the 15-lead. Alas, I don't think one was done. An oversight. However, luck was on our side. The fellow did ok for the flight (...not me..) and an angio showed a 95% occlusion of the LAD. Plus some other areas of concern. I called. I was wondering.
There are a couple of things I liked about this case. One, it made me remember Wellen Syndrome again. Also, the fact that this was an atypically presentation. Normally, from my experience and from what I have read Wellen Syndrome is pain less and a forerunner of more serious troubles to come.
What I think is this fellow had these depression (v1,v2,v3) for quite awhile before he came in. I am sure if he hung around in the ED his ST would have started to rise at some point.
Cheers
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Hello,
This patient was transfer out for angio by fixed wing. The Dx was NSTEMI (he had a postive Tn-I).
His pain was an issue. EMS gave one dose of Morphine. He got sick.
We gave one dose of Morphine(with Gravol) in the ED just before the flight team arrived. Emesis++ and he had mild allergic reaction. So, we tried some Fentanyl IV. This worked well and he settled. Less pain. Less anxiety.
He left on NTG at 100mg/min. The crew d/c the Labetolol infusion and gave Fentanyl PRN, Metoprolol IV x3 and called it a day. BP was down in the 140 range and his heart rate settles around 80 or so.
As a side note, the EKG (t wave depression) fit the classic patter of Wellen Syndrome. Anybody with Dubin's EKG textbook will find it in there. Also, I read a article called 'Wellen: The Forgotten Rhythm' as few days before this. So, it was fresh in my head!! =)
Here is a link about it:
http://www.onlinejets.org/text.asp?2009/2/3/206/55347
Cheers
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I need to agree. ACS would be my first choice of DD and any treatment of such would be more than appropriate. However, I am not 100% convinced that it really is ACS. I would continue to work through my other DD's as necessary.
Dave,
Upon exam, were there any findings to the neck or back with palpation? IE tenderness, radiation of pain, traumatic finding.
Did the pt take his medications the day of the call? Specially seeing how the patient has a history of HTN, Anxiety and chronic back pain.
Your "Bandlike" finding makes me wonder if this is more MSK and involving a dermatone and some type of nerve impingement, etc.
The great part is that the treatment for ACS will help with the HTN and anxiety if MSK is found to be the underlying cause. My only concern would be what traumatic findings on exam you would find, if any? And whether they would necessitate any spinal precautions?
Hope you follow up soon.
Hello,
Sorry for the delay. It has been a gong show around work.
The patient has taken all of his medications. Also, his BP is usually well controlled (according to pt).
The patient kept describing the pain as 'sqeezing' and 'band-like' with numbness to his right arm. Good question about the dermatone. I never though about checking this.
The neck had noraml range of motion.
Dave
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Hello,
Ok, so the crew arrives at the hospital. They treated with NTG, O2, ASA and gave Morphine 2mg IV.
On arrivial, his VS are as follows:
GCS 15/15
BP 200/100
HR 110 S.Tachy with depressed T-wave in V1,2 & 3
As he is being transfered from the cot to the bed he has an epsiode of emesis and still is c/o a numb arm and 'band-like' sunsternal pressure.
An u/s and CT is done and no AAA is noted. CXR shows claer lungs. A stat Tn-I is elevated at 0.80. Lytes are normal and Hbg is normal.
Also, serial 12-leads show no changes.
He is started on a NTG drip (80 mcg/min) and Labetolol infusion (.5mg/min). Given an other ASA, Plavix 300mg, Lopressor 5mg IV, Enoxaparin 100mg SQ (he is 100kg). His BP is lowered to 130/50 from the infusions. He is still tachy (100-120). More worrysome he is still having chest pain that he describes as 'bad'. No addition pain control has been given.
He is being transfer out for angio and admission to a biggger CCU.
You are the fixed wing flight team. Transport time is a hour. What are your thoughts?
Cheers....
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Hello,
Sorry about that I was having issues with uploading the image. It seems that it has to be less than 3.7K. So, I need to upgrade my membership and get better at this.
CNS:
A/O x 3 and no focal findings
No H/A, photophobia
CVS:
The BP is the same in both arms (200/110)
Tachy
Cold Sweats
EKG-----> Inverted T-wave in V1, V2, V3 No 'q' waves, normal axis, and good 'r' wave progression.
The crew gave SL NTG x 3 and ASA. Started a 2nd IV and transported. The BP wasn't lowered by the NTG.
Cheers
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Hello,
Ok, we are thinking about MSK pain, CVA and a AMI.
So, ALS arrives, and dose an assessment.
The patient is alert and orientated (GCS 15) with no deficits found. His pupils respond to light. Additional findings are the same as the BLS crew. They also place the patient on the monitor and do a 12-lead EKG (see attached....this is not the original...sorry).
So, what other interventions are we thinking of here?
Thank you....
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Hello,
Here is an interesting case that I was involved with the other day. I would like to just work with the pre-hospital side of things for now. Then deal with the hospital side of things and a transfer.
Case Presentation:
A 52 year-old male calls 911 complaining of shoulder and neck pain after seeing his Chiropractor. Initially, a BLS ambulance is dispatched. On arrivial the BLS crew notes that the patient is plae and soaked in a cold sweat. He is very anxious and in obvious distress.
Physical Exam:
Physical exam finds that the patient is anxious, tachy (120's), hypertensive (220/114), and tachypenea (30's). SpO2 = 95%. His lungs are clear. Skin is pale and soaked in cold sweat. No JVD. Beeds of sweat run down the patient's face. Pulses strong and regular x 4. No N+V. No GU issues.
He describes the pain as 'numbness' in his shoulder and right arm and scores it as 9/10. He also states that his chest feels tight. Like a band squeezing him. In addition, the patient had had similar episodes over the past two weeks. However, the pain was quite mild in comparison. Nothing in particular caused the pain and it just 'Went away on its own.'
History:
Past medical history is obtained from his mother and sister (who are quite anxious). They state that he has a long history of neck and should pain which he see a Chiropractor frequently. They add that the Chiropractor didn't do aggressive manipulation of the patient's neck. He also has a history of HTN, Anxiety, Depression, Dyslipemia and Cancer (...not sure what type...but treatment was effective...). He also quite smoking 15 years ago. His only drug allergey is to Ativan.
Currently, he takes Ramipril 10mg PO OD, Immovaine 15mg PO QHS, Lipitor 40mg PO QD, and Advil PRN, Tyl PRN, and Tyl#3 PRN for pain.
Family History:
Noteworthy family history includes a father who die of a MI a 50. A family history of depression and suicides.
Current Situation..........
The BLS calls fro ALS and insert a #20 IV in the patients left hand (...a hard start...) and place the patient on nasal canulas at 3 lpm. ALS arrives shortly. Total scene time has been 10 minutes so far. They hospital is 15 minutes away. They have a good ED, ICU, CCU but no ango.
ALS has 12-lead EKG, CPAP, TNK and ALS medications.
Thank you.......
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You are also not going to be able to do an "ARDS" ventilation protocol in the field and doing just parts of it without full access to all the buffers and medicaton protocols for low volume high PEEP dump the BP and pH. If your volumes are too low when you back off on the PEEP, you will set the patient up for atelectasis which decreases the ability to oxygenate/ventilate and then re-expansion trauma later if the opening pressures are high. An iSTAT would also be nice to know where your pH is before you try to manage a ventilator for "ARDS". You may have to run THAM (preferred) or NaHCO2 but then her Na+ might be high or the metabolic condition may not warrant it as a buffering agent. THAM is more useful for the permissive hypercapnia.
http://www.survivingsepsis.org/SiteCollectionDocuments/2008%20Pocket%20Guides.pdf
Hello,
Oh, do an APACHE II score to see if Xigris may be needed.
I guess, in effect, the stuff laid out in the Surviving Sepsis document posted above.
One question, what is THAM? I assume it is an alternative buffering agent of some type.
Just wondering how the rest of this will play out once you arrived at the ED.
Cheers
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Hello,
Thank you for a new case study.
I think pneumonia/sepsis is a solid dx. Throw in a little post intubation hypotension as well. Give a fluid bolus (1L). Odds are that should almost be in by the time you arrive at the ED. Maybe, with luck, get an IV in.
If it is pneumonia/dehydration. Fluids will sort that out as well to a certain extent.
Besides, if the ED is switched on, this lady would get a central line (CVP + meds) and an arterial line as well. Get her on a vent (AC with PEEP), do a gas, and hang some sedation. Snap a CXR. Foley. More fluids. Labs. Find out more of her history. The usual.
If it is smaller center. Grab a coffee and wait for the call for the transfer to the local university hospital... LOL
Cheers
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Hello,
"The AIT agreement was a legislated and signed document by the provinces to decrease trade barriers, best read the entire document first and foremost please. This is not clearly a one way street the destination being the very lucrative Oil-Patch industry in Northern BC and Alberta. So tell me it is't so and I have 30 'medics' and names doing just that, this very minute. Those that have actually gone through the process of reciprocity and we are richer for this in some ways, but damn near none are working on the Streets of Alberta PERIOD! but yet again your duped into believing there is not already avenues open ... say like taking a program in that province ?"
Who cares if Paramedics come from outside of Alberta to work in the oil patch? If they do not want to work in the 'streets' and go for the easy cash of sitting on an oil lease....so be it. That is their choice. They are professionals with needed skills. Therefore, the can work with whomeven they want. IMHO.
The same goes for schools. If a student wants to go to SAIT as opposed to SIAST....again who cares. If they are accepted by the school and meet the schools standards I do not see the issue.
As for EMS in Alberta and BC being under siege. I can not comment on Alberta at the moment. But, BC I agree in many ways. Labour issues. Part of the transfer budget has been given to the health authority. Rumbling about moving EMS and transfer services to health authorities as well.
I guess....time will tell how things play out.
Tniups. It is obvious that you are passionate about this issue and have strong ideas. This is a good thing. Have you consider trying to develop a political solution? Work with a union? Develop a group to promote EMS in your area? Get your views in the press?
So, get involved in this process of change. Look at the good example of EMS in Canada (EHS NS...Provinical System) and ones that becoming somethings better (Eastern Health...ACP for St John's and new flight service...a Health Authority System).
Cheers
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Hello,
If the patient was having a MI I think the risk of a bad outcome here from pushing the D50W is quite small. If he wasn't having a MI.....then no big deal.
Really, even AMI patients admitted to hospitals who are managed with an insulin infusion have spikes in BGL. Also, most MI DIGAMI protocols (..that I have seen...) only start if you have had TWO sustained BGL ( <10mmol) in a 4 hour period.
Second, I think the point here is to discuss elevated BGL in the MI patient. Not to start a flame war. Of course one should treat the patient and not the machine. Of course understanding the pathophysiology and the physiology is important as well.
Did the crew make a mistake? Maybe. But in all honesty who knows with the information that we have. Maybe he was drowsy, confused, sweating, pale and c/o chest pain. They were having equipment issues. Maybe they we new and nervous?
What is worse......an untreated episode of hypoglygemia or worsening a marginal case of hyperglycemia (150mg/dl = 8.3 mmol)???
Was it their best day....odd are no. I have seen worse and I have done worsen (...we all have...)!
As for ketones. I think it would be hard to have ketones with a bgl of 8.3 mmol. IMHO.
Cheers
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Hello,
Here is something interesting that I found the other day in the library at work. I was kicking back in a comfortable chair on a coffee break and I saw an Annals of Internal Medicine on the desk. Sorry I can not cite the actual journal......
But, it was a review of management of BGL in ICU patients. Some interesting facts came to light.
1--> Management of BGL has been proven effective in cardiac patients (DIGAMI) and for surgery patients only (study...can't recall).
2--> BGL control have been applied to other types of patients without as of yet controlled studies.
3--> Therefore, control of BGL in other ICU patients (sepsis...for example) is uncertain for a couple of reason.
A------> Tight glucose control (...and the r/o hypoglycemia...) worsen outcomes.
B------> So, is a higher range (...high normal?...) better for non-cardiac or non-surgery patients?
C------> Or, management with sliding scales?
D------> Or, management with oral/NG/OG medications?
For example, point 3A. Our insulin infusion gtts has a goal of 4-6 mmol. Sometimes, keeping it there is like balancing on a tip of a needle.
Time to go. Sorry for the lack of citations. I will try and track theme down. It is hard to type and watch a my 3 year-old daughter at the same time!
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So my partner and I were talking about a call in our service where someone gave an amp of D50 b/c of a misread glucometer. They believed the pt. was hypoglcemic when in fact BGL was aprox. 150. (non-diabetic pt.) It was a CP pt. I didn't believe an amp of D50 would be too harmful, as I thought it would be absorbed pretty quickly.
My partner stated if the pt. was having an MI the amp of D50 would worsen the MI by making the blood more viscous. Thoughts on this?
I couldn't find anything to support his claim. I thought this mistake was pretty harmless.
Hello,
Elevated BGL worsens outcomes for AMI patients. This was demostated in the DIGAMI study in 1995. However, it is not due to viscosity from my understanding. Elevated BGL worsen the immune/inflammatory response.
However, in this situation, a brief increase in serum glucose wouldn't be dire....IMHO. If in fact this fellow had a STEMI or a NSTEMI his glucose would be normalized with an insulin infusion or sliding scales insulin.
The risk is a prolonged elevation of serum glucose.
Cheers,
DD
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Hello,
Here is some interesting news that I read online and transfering EMS to each health region;
http://www.timescolonist.com/business/looks+privatizing+ambulances/2549719/story.html
I have heard some rumbling about this at work.
I would write more (...want to...) but I need to run to my NRP re-certification.
Cheers...
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Well the way I look at it is somewhat different ... Why not go to the Media ... is it JI's fault that Comrade Campbell er (Vanoc) stated this mess ?
This would be my first option if I were in the OPs situation.
Realistically there are 4 parties responsible (the Primary already noted with forced OT and Bill 21) the parts that statred this pissing match so hold THEM responsible.
2- JI for a financial commitment to provide training and then no "back up plan" for placement ie field practicums, the JI putting all the bread in one basket is folly Dartmouth Dave.
3- BCAS and ultimately one of the biggest negative influence's as the entire the stepping stone or mother please may I politically interwoven EMS system, some non voluntary early retirement packages should be a tangible idea, you so need fresh blood in BCAS.
4- CUPE - Interesting that the membership (although stating publicly that they wish to address response and staffing) put the brakes on in the area of professional development, to the public it appears (those with half a brain) that this is hypocrisy, quite frankly it appears to be an attempt at "punishing" tactics, it reflects VERY negatively.
As for technocardy's advice meh the wait and watch approach has not worked effectively in the past in BC ... so do the math and 350 students x ______ =(the ca$h invested) .. use a legal solution OR a political solution, sitting around waiting is just not going to solve anything.
Or then again just Move Away to where the grass is greener, avoiding ALL the trolls under the bridge, this may be far more effective and timely with AIT reciprocity these days, just saying.
cheers
Hello,
I agree with your points about CUPE (#2) and BCAS (#3).
But not with #2...The JI.
Again, how can an organization (...though flaw in many ways...) be responsible for a labour dispute between CUPE and the BC government that has fermented into a toxic situation?
What back-up plan could they have made? Finding spots outside of BC for clinicals? Is that pratical for 350 students? No. How many PCP students living in Vancouver could afford to spend three weeks (...or more...) living in Edmonton, Calgary or Red Deer for example?
What about the different scope of practice between BC and Alberta BLS. Such as 3-lead EKG, doing 12-leads, King-LT to name a few. All things not covered by the JI's PCP program.
Crew set up (i.e. ACP/PCP).
Lisecening issues between BC and Alberta. How many PCP students could afford or be will to pay to get an EMR lisence from Alberta College of Paramedics? Because the JI wouldn't be flipping this bill....
I am sure I could come up with a few more things as well.
So, yes it sucks. I feel bad for all the folks stuck in a mire because of this strike. Students. Paramedics. The public. But, 350 screwed students are not going to pull of a coup d'etat and get their money back from the JI.
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Hello,
-----> WOW! You Paramedics must get big great money up there in Whitehourse to walk away from an incomplete $6000 course.
I wonder if we have read the same messages?
Do what you want. Try to get your money back if you want. Just hang in there get things done if you want. Heck, I know a few people in your situation. Waiting for their ACP clinicals. I have friends in the Army waiting to finish their PCP programs as well. Your lot in life isn't unique. Just don't act brashly.
-----> Something tells me your work for the JI
Am I a big supporter of the JI? No. The school has issues. However, despite issues within JI how can they be accountable for a labour dispute between BCAS and the BC government? Sure...follow that logic and if there was a nursing strike all the universities would have to refund their students? An RT strike? An OT strike? A PT strike?
The best of luck with whatever option you select. However, one can not solicit advice and get frustrated with the responses.
Cheers
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Hello,
WOW! You Paramedics must get big great money up there in Whitehourse to walk away from an incomplete $6000 course.
I wonder if we have read the same messages?
Do what you want. Try to get your money back if you want. Just hang in there and you will get things done if you want. Heck, I know a few people in your situation. Waiting for their ACP clinicals. I have friends in the Army waiting to finish their PCP programs as well. J
Something tells me your work for the JI
I am big supporter of the JI? No. The school has issues. However, despite issues within JI how can they be accountable for a labour dispute between BCAS and the BC government? Sure...follow that logic and if there was a nursing strike all the universities and colleges would have to refund their students? An RT strike? An OT strike? A PT strike?
The best of luck with whatever option you select. However, one can not solicit advice and get frustrated with the responses. Sure, your in a frustrating situation. But,
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Hello,
Go ask the JI for your money back. Good luck.
I am sure they will claim that it isn't their fault for the delay because the strike is out of their control. It is an 'external' issue between the BC government and CUPE.
If all you have left is an ambulance clinical just wait for things to sort out. Otherwise, you would have wasted a great deal of time and money.
Cheers
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Hello,
Any other point I would like to add is access to education. Why is it that one has to go to Vancouver to learn how to be an ACP? Or, why is there a lack of PCP programs in BC?
Part of the reason ACP and CCP make lots of money (...tons of OT...) is the fact that becoming an ACP is problematic for may senior PCP staff. Travel time. Time away from families. Limited ACP posting (ALS stations). The fact that becoming an ACP will require many BCAS staff (..and families..) to relocate.
Add to this the difficulty for Paramedic from outside of BC getting reconized in BC.
This all creates a self imposed bottle neck that makes training new ACP and CCP staff difficult.
It will be interesting to see how the strike goes this spring. CUPE is in a bind that is for sure. Not the best time to pushing for wage increases and more positions. This report won't help at all!!! Also, I wonder if there is an agenda to break up BCAS and transfer EMS services to each of the health regions.
David
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Hello,
There is some truth to this report.
If you have a good PCP position the pay compares very well to the rest of Canada. For the ACP/CCP one can make well above the Canadian average for EMS. For some reason in BC every year the Provinical government publishes the names public service staff that have made more than $75,000.
I can not seem to find it online now (for 2008-2009). However, the unit chief for the ITT made $250,000. It also showed that ACP do very well. CCP even better. ($100,000+ easy). (Sorry...no refernce for this statement)
However, if the wages were ploted on a bell curve it would be skewed big time to the left. You would see pile of people on the lower end of the wage scale. These big saleries do not repersent the rank-and-file BCAS staff.
More full-time positions are needed.
Get rid of the driver positions or the EMR level. Really, is there a place for a guy with a class 4 and an EMR in a modern EMS system?
More ACP and CCP as well. Start doing inter-facility ALS transfers (...as opposed to making hospitals provide staff...). Get more planes.
Improve the BLS level of care. Again, is it acceptable for a modern EMS system to bring a sepsis patient to the ED without a line becasue they do not have the certification or training? Becasue, from what I have seen , BC has two levels of BLS. Level one is o2 and transport. Level two actual quality BLS care. IV, narcan, et al......
Ok...I am done. This post got away from me a little bit.
Lastly, this post isn't an attack against BCAS. Or, ment to pick on those making a good living with BCAS. I just think that the wealth could be spread around some and training could be elevated some.
Cheers....
David
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Hello,
Some interesting news out of BC. These two articles are about the Trumpy Report. The second one has actual details from the report.
Not the best thing to hit the press with the strike (..the sequel...) looming this spring.
Cheers,
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Hello,
I wanted to add an artcile on Myocarditis from Up To Date but it was too big.
However, he is a slightly related one on RVI that is interesting.
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Hello,
Really, if your transport time is short the prudent option would supportive care until you get to the ED. Just be ready if things go down hill during the 15-20 minute transport.
I am not saying 'scoop' and 'run' with everything and let the ED sort it out. But, EMS should be an extension of the ED. In the ED he would get supportive care and a work up to see what is going on. Why should the EMS standard be different?
He has signs if right sided failure (edema and JVD) and signs of left sided failure (rales and pulmonary edema). Signs of a infectious process (general malaise x 5 days with a fever). Cardiac issues as well (1st degree block/bigeminy with an elevated DBP).
Plus, a solid list of unknows.....
Renal...what is going on? Any failure? Urine output?
Lytes? K+ Mg+ Phos? et al.... Fluid status? In he dry intavascular?
CBC? Hgb?
LFT?
Tn-I
Blah...blah.... =)
So, Kiwimedic.....what is going on here?
Cheers,
David
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Seizure with Hematuria
in Education and Training
Posted
Cheers