DartmouthDave

Hello, Yes, sad but true. The wife waited four hours to call EMS and has opted not to come home from work. =( SUMMARY OF INTERVENTIONS: -Basic Airway Management -Atropine -Glucagon -IN Fluids RESPONSE TO INTERVENTIONS: The patient still has a weak gag and won't tolerated an OPA. His airway is suctioned for thick secreations and with O2 his sats creep up to 85-86% Atropine has little effect on the HR Glucagon IV causes a slight rise in BP (90/42) and HR creeps up to 60 The fluid bolus pushes the BP up slightly more to 95/50 with a marginal improvement in skin colour. Cheers

Hello, A quick calculation surmises that it looks like 20 x Metoprolol 100mg tabs (2000mg) and 20 x Verpamil Sr 180mg tabs (3600mg) and 80 x Advil 200mg (16000mg). You also note 8 beer bottles on the floor. No medical history is available. You start the treatment as noted above. The EKG shows a Sinus Bradycardia with a 1 degree block. Cheers Cheers Hello, The EKG shows Sinus Bradycardia with a 1st degree block. A head to toe shows an obease male with cool clammy skin. You note what appears to be diabetic foot ulceration on both feet. Last seen normal 4 hours ago when he called his wife at work to tell her he wanted to 'suicide himself'. Cheers

Hello, Scene is quite safe. You assess the patient: GCS:7/15 (E1 V1 M5) Pupils: PEARL@3 BP: 82/40 HR: 50 (Sinus Bradycardia) SpO2: 82% Resp: 8 Lungs: clear Temp: 35 BGL: 18 mmol You read the bottles on the floor: Metoprolol 100mg tabs, Verpamil SR 180mg and Advil 200mg. A suicide note on the table states that I took 100 pills and I want to die. Cheers

Hello, Here I go again....lol You are dispatched to a suburban home for a suicidal patient. The patint's wife called EMS from work because her husband has tried to overdose himself, again, four hours ago. She said the door is unlocked and the Paramedics can let themselves in. On arrivial you enter the house with the RCMP and find an obease (150kg) 47 year-old male patient sitting on the couch. There are empty beer bottles and three empty pill bottles on the floor. His colour is ashen and gurgling sound can be heard from the door. The room smells of feeces and urine. Cheers

Hello, Sure, I guess by that standard one a patient would need a pair of depends by 40? =) LOL

Hello, I think that this patient's medical history caught up with him. Maybe he was a little septic (Temp of 35) but who knows. The only 'eyebrow' raise is for ED thinking about Dopamine with those second set of VS. Of course, hard to say what they were thinking. Cheers

So when a patients Measured Minute Volume it must exceeded by a factor of 4 minimum, that is called a true High Flow System btw.<edit delete I:E ratios nonsense and say 1:4 is acceptable. So when one is breathing at 10 liters per minute, 10 lpm is extremis (normal MVs are average 3.5 to 5.5 lpm). Upon rapid inspiration and quite easily one can achieve 40 liters per minute, a patient can out breath or suck back for lack of fully functioning brain cell's at this juncture. ON ICU ventilators 120 lpm for flow rates are achievable ... that's to match the demands of a thoroughbred at a full gallop, if you catch my drift. So in order to maintain PEEP The machine/ device whether it be a CPAP device BiPAP or a Ventilator or even a BVM with PEEP Gauge, once again inspiratory flow must exceed the MV x 4 so that the end pressure is not lost, to zero. If you do not a device that can exceed the positive pressure during inspiration then "demand exceeds supply" (for the economists out there) then one cannot assure loss of so ask yourself when looking at any device is this capable of even accurately measuring end exhalation pressures or is it just set somehow with flows and magic theory's ? Because if it is not and no way that you can measure, therefore "you may" or "may not' be maintaining PEEP. Hello, Night shift so bear with me. My question is weakly related to the discussion thus far. OK. Flow needs to be x4 the MV in order to maintain PEEP. So, with a transport vent (LTV or Oxylog 3000...for example)dose this mean the PSI drained from the oxygen tanks increse as PEEP is increased? Cheers

Hello, That is very interesting. The only time I have seen it used (very rare) was for high grade SAH in order to prevent the dome-like blood clot from break down. Or, when I was a student in a CVICU. Not sure why it was used there. Cheers

Hello, Doc's post covered things nicely. But, I would like to add one small thing. I think inserting an OG is a better option than an NG in an intubated patient for a few reasons. It is easier (even more so if a paralytic was used), no worries of a baslar skull fracture, epitaxis, or a sinus infection tracking down the NG. Cheers

Hello, Late to the threat. Reasonable stable. So, Amiodarone 150mg followed by 1mg/min. With pads on just in case. Transport. From what it is worth I typically use the following system to try an see if a WCT is VT. Many of these points have been already raised. 1. Cardiac Hx? 2. Risk factors? 3. Old CAGB scar? 4. ICD (Internal Cardiac Defib...a square lump under the skin on the upper left or right chest) 5. Axis? 6. BBB? 7. Rate? 8. Variance of rate and QRS. Slows down with fluid? Dose the QRS change with rate? 9. How long has the patient felt unwell? Though rare, I have seen a few cases in which the an IVCD develops due to tachycardia. Last winter, a 80 year-old gentleman was brought in with a WCT that was refractory to defib. It turn out he was feeling unwell and was dehydrated (Hence my addition of point #8 & #9). Cheers

Hello, I have never seen it until I started working at a new facility. Also, I would like to add that I have only seen it done a few times. I was wondering if other the posters had heard of the pratice. Excellent discussion so far. I recall a very sick ARDS patients that needed to be transfer by air ambulance. Transport time was long. When the patient was transfered from the ICU vent to an LTV1200 things went poorly. I was wondering if clamping would have helped. I guess not. Cheers

Hello, I have seen it done with HFO (High Frequency Oscillitory Ventilation). But, not for other patients, so far. I have a fair number of occasions in which a patient is changed from a hospital ventilator to a transport ventilator (without clamping) and things go poorly. Low volumes and high pressures and falling sats. It takes quite awhile for things to come back around. Cheers

Hello, I have done some research and I have not found much information on the subject. You have an ARDS patient (or any patient for that matter) that requires a great deal of PEEP. The patient is being transport from point A to point B on a transport ventilator. I know every time you break a circuit you lose recruited lung volume. I attended an excellent lecture in which a pig lung was ventilated and when the circuit was broken it took a long time for the lung to puff up again. I also see frequent issues when a patient is changed from their hospital ventilator to a transport ventilator (with the assumption that the transport vent is meeting the patients needs and the operators are skilled). I have seen a few HFO patients. The ET tube is clamped if the circuit has to be broken. I am not sure, but I think clamping of ET tube occurs in NICU for similar reasons. So, here is my question: Would clamping an ET prior to breaking a circuit help prevent loos of PEEP and FRC? Thank you, DD

Hello, Yes, I missed your post with the question about the productive or non-productive cough. However, my last post's purpose was to acts as summation of what various posters were discussing (AussieAid, Tniuqs and yours). I like to post interesting patients that I see and have seen over the years for something to do. I am not in it to snub people. Second, I do not have as much time as I use to type out responses as well. That is a factor as well. So, if I have offended you I am sorry. Cheers

Hello, It turned out that the patient had GBS. Care by EMS was supportive in nature (O2, pain control, IV). In the ED he had a CT to rule out a AAA. The back pain was related to the progression of the GBS. Odd, but true. The patient also required a tube shortly after arrival in the hospital. Excellent work everybody. Cheers PS..... BTW, if he needed intubation in the field what drugs would people use? =)

Hello, The legs are flaccid with no sensation. LOC is 15/15 and end organ perfusion is acceptable. No fancy kit like an iSTAT. The lungs are still clear. The dwell is clear. No sings of infection and no edema or sings of infection in the legs. Just poor colour, temperature and a weak pulses. Which is a normal state for this patient. The PD cath is clean and well care for. So, your on the way to the ED. The patient settles some with MS (or Fentanyl). His rep rate is still in the 30's and his stats are 90% on a NRB. The back pain has also diminished some with the pain control. Here is the million dollar question: Is is GBS or a AAA? Cheers Happy New Year

Hello, I was just listing all the possible Dx present in the discussion so far. Sorry about forgetting to post the BP sooner. Trying to post during breaks at work isn't a good idea at all. OK, so you have a couple of IV and place the patient on a NRB and transfer him to the stretcher. An addition set of VS are done as well. GCS: 15/15 Arms: Strong Legs: Absent motor function Resp: 30's Rapid and Shallow SpO2: 91-92% EtCo: Not available...sorry EKG: Sinus Tachycardia 120`s BP: 160/78 Temp: 37 You drain the 3L dwell from the pt abd and no pulsating masses are note. He feels better with the pressure gone from his abd. He still complains of a bad back pain as well. Cheers

Hello, Good grief.....I am cringing reading my last post. No...just the endless night shift. His BP is 160/80 Off to bed. Cheers

Hello, Their was consideration or Eprex but the Nephrologist. The 'Zythromax' is indeed 'Zithromax'. Yes, a typo on mybehalf. This is based on a patient that come through the hospital that I am working at. It was a confounding case for all parties involved. Here is a list of Dx we are working with: 1. CHF 2. AAA 3. GBS 4. PE 5. Vascular Crisis Here is a summation of the physical findings and physical assessment: 1. No weight gain..he is his normal weight 2. Lungs clear 3. Feet are cool...but they are the same that they have been for years 4. He has pulses in his feet....weak but present 5. He had a pneumonia two weeks ago that has cleared up 6. He normally can walk short distances and now he can not more his legs 7. He has diminished sensation in his legs Also, I forgot to note, that his surgery was a couple of months ago and his recovery was average. Cheers PS: A quick response from work (an endless night shift)

Hello, The has been on Peritoneal Dialysis (PD)for the past 5 years. The patient and his family are very catious and dedicated with his PD. Currently, he has a 4.5% solution in situ. So, his abd is large, distended and full of fluid. Careful records of the patient's PD have been kept by the family and his weight is normal for him at 80kg. The patient has had trouble with a low Hgb for quite awhile and his "specialist" was considering "shots" to help make more red blood cells. His skin is pale with a lack of hair on his legs and a crimson red appearance of his feet. His family states that his feet have looked like this for quite awhile. His current medications are: ASA, Multi-vitamins, Insulin, Calicum, Vit D, Thiamine, T#3 and Metoprolol His VS: GCS: 15/15 Anxious and Scared Pupils: 4mm+Brisk Arms: Strong Leg: No movement, flaccid with diminished sensation Lungs: Clear Rate: 30-38 SpO2: 84% on RA EKG: Sinus Tachycardia with an old BBB (120-130 bpm) Pulse: radials-present / pedials-very weak (feet a cool to the touch) Temp: 37 GI: distend (fluid in situ) Blood Sugar 15mmol The patient is c/o 10/10 lower back pain. He has had back pain before but not this bad. Cheers... need to run...break is over!! So, pardon the typos please =)

Hello, You are dispatched for a 67 year-old male with a complaint of numb feet and trouble breathing. On arrival you find the patient sitting in bed with three pillows behind his back. He appears pale, diaphoretic, anxious with increased work of breathing. The patient had a bad pneumonia two weeks ago which he was on Zythromax. Things seemed to have gotten better and the patient was feeling more like himself. He was able to walk short distances and get up and down the stairs. Then, over the last 24 hours, the patient experienced a burning sensation in his feet. Which has progressed to worsening weakness in the patient`s legs and very bad lower back pain. Over the last few hours the patient has experienced worsening dyspnea and feels like he is dying. His family says he is so weak that he can no longer more his legs very well. The patient has a history of NSTEMI in 2007, CHF, HTN, DM, Dyslipemia, OA, CRF, as well a severe PVD with a Femoro-Femoral Bypass surgery in 2009. Cheers..

Hello, So, the EKG shows a wide complex tachycardia (WCT). Is it VT or Sinus Tachycardiac with a aberrant conduction. I would lean towards VT because: Young and resonable healthy lifestyle (if I recall the 1st post correctly) No cardiac histroy Negative stress test Slim chance that she has a preexisting BBB So, I think I would: 1. O2 2. Keep the fluid running 3. Defib x 1 (because she is unstable) Now, as a remote DD: 1. Hyperthyroidism (causes anxiety, tachycardiac, mood swings, anxiety) I have seen two female patients with PSVT refractory to cardioverson and medications due to hyperthyroidism. Sorry, need to run, at work. Cheers Sorry for the brief post.....

Hello, Typically, a patient suffering from withdrawal (etoh, benzo, opiates, ect...) will demonstrate psychmotor agitation, fever, tachycardiac, hypertension, N+V and diarrhea. In fact, I got burned once by a Nun. I thought it was an acute abdomen because of diffuse abd pain, N+V, diarrhea, temp (38 degrees). She looked like hell (nice pun). This fellow has a mixed OD of MSIR and ASA. His glucose is normal. But, an ASA OD can block the uptake of glucose in the brain. Time for pre-night shift nap. Cheers

Hello, I think ACP start at around $25 in Nova Scotia. I will ask a friend who just started with Emergency Health Services NS to confirm this. A bit less than say ONT or AB. But, from what I have seen a fairly progressive service. Also, on a side note, their are Clinical Paramedic jobs as well in the various ED. The medic do triage, sutures, splints, and respond as a part of the code team. Cheers... I hope this helps