FireEMT2009

Nope, no, and nope. And its never Lupus! Nope, no, and nope. And its never Lupus!

Hey everyone, Sorry for the delays in updates on the scenario in my last two weeks of medic school so everything is wrapping up. Anways back to the scenario: His feces is watery diarrhea with no mucous, blood, or anything abnormal. You find his tempature is 105 degrees. You note no crying, salivation, urination, etc. Continued assessment? Treatment? You also note that he seems to calm down a little bit after administrating the ativan but his heart rate is still high. His pain is untouched from the administration of nitroglycerin and ASA. He says he now has a headache. Vitals are now: 180/80 Pulse-155, RR-22 SpO2-98

I forgot to mention that he states that he has been eating and drinking like a horse for the last couple of days and has had constant diarrhea and just can't seem to stay full. The 12 lead shows Atrial Fibrillation at a rate of 160 and irregular. No ecstasy or performance enhancements drugs found and patient denies usage of any illegal or performance enhancement drugs. Nor is he doing any type of cleanses. He has been doing his regular baseball routines like he does everyday, nothing changed. Patient has not taken benadryl. Keep going ya'll are doing well.

Lets get a closer look at the scene. You enter the residence and you see nothing out of the ordinary. They do not use gas in their house. You find a 20 year old male patient pacing around the room in only his undergarments. He is red and sweating profusely. He states that he just can't seem to cool down. You also note that it is around 65 degrees in the house and it is around 75 degrees outside. Your patient is awake, alert, and oriented to person, place, time, and event. Your vitals are: BP- 200/90 Pulse-160 RR-24 LS-Clear Pulse Ox-98 BGL-112. Medical History- URI earlier this week being treated by PCP with amoxicillin. Allergies- NKDA No food allergies Pain- located somewhat in chest but is only a 2/10. Skin- Red, hot, diaphoretic Nothing else remarkable. Plays baseball religiously and does not use drugs because the team would kick him off for using. Continue assessment. Whats next for this guy? DDx?

You are working in a rural EMS system you are on a three man truck which is made up of two EMT-Bs and yourself (Medic, B, what have you). You are dispatched to a patient having chest pain. You arrive at the house to find a professionally cleaned house with nothing noted on the outside. Scene is to be considered safe until further notice. Two people meet you at the door stating that they are the parents of a 20 year old male patient who is inside having chest pain and shortness of breath, not acting right. Go.

Also Defib I thought I would mention it this: Don't gender dependant toxic shock syndrome. Males from my research get it more often than females and you can also see it in children. It is rare that you will ever see it. The tampon related toxic shock syndrome cases that were found in the 80s made it seem like only women could get it.

Yea I was just curious about what those member status' meant.

Yea she needed clotting factors and blood trasfusions stat, though unfortunately we do not carry those on ambulances, at least not yet. The program I am in is a bachelors that allows students to concentrate in firefighter/paramedic studies or critical care paramedic studes. I am glad you enjoyed it. I will continue posting more scenarios like this. I have one in mind that I will start up soon.

Every disease can show up without certain symptoms. Toxic shock syndrome stems from staph aureous or streptococcus group A bacteria that enters the blood stream which will cause widespread, rapid, and rampid sepsis. The two bacteria I mention is usually found on the skin all the time. Both of these bacteria can also cause necrotizing facitus. Both of which made very interesting research papers. And thanks for the feedback I'm glad you enjoyed and learned alot from the scenario. To get a better view of the "rash" that I mentioned earlier go to google images and search disseminated intravascular coagulation and it will show you the pictures of the "rash". And since I'm still considered a BLS provider until I test for my medic I love to get both BLS and ALS providers treatment plans because everyone thinks differently and will pick up stuff that others missed.

Disseminated Intravascular Coagulation. It is where something traumatic or other reasons that causes the blood to start clotting throughout the body in the capillaries. It can cause DVT, heart attacks, strokes, etc. Your body will continue to clot until your body runs out of the clotting factors in its blood and once that happens your blood will no longer clot and any cut will not stop bleeding because of the lack of clotting factors. It is like hemophillia but is caused secondary to something else. This scenario actually is DIC, I wrote a 18 page research paper on it and had to present a scenario on it to my paramedic class to see how they would treat it. The scenario ya'll have been running through is the exact same scenario I wrote and presented. Up to 60% of all OB/GYN emergencies such as, abrutpo placentae, fetal demise with prolonged carrying of the deceased fetus; also trauma or sepsis can cause it. When you mentioned toxic shock syndrome earlier it made me laugh because I wrote another research paper on it a couple of semesters ago. Our papers required us to research the patho, etiology, epidemology, and prehospital treatment for it.

I have noticed that under my name it reads as EMT City Freshman and on others it reads as Elite Members or EMT City Sophomore. What do those mean and how do they change or can you change them?

Your patient now has an ETT in place confirmed correctly by condensation in the tube, capnography, breath sounds, and espoghageal dectector. Good call, what would your treatment be Island? This patient is definately not doing well, I fully agree with that. Even after suctioning you still find that her airway is still filling up with blood, and that your IVs still have blood coming from around them and the hand is still bleeding vigorously.

Thanks croaker, I was just referring from the contraindications that were listed in my pharm book, it doesn't give realitive contraindications it just lists it as contraindications in general. I hope you truly didn't think I was being a smart ass or anything by mentioning that cause I truly wasn't. it is justification for airway management, since you selected ETT, you pass it without the use of any drugs, sedatives or paralytics. Thanks for the information I need to do a little deeper studying of drug contraindications then apparently. I agree it could be sepsis I was just curious to your thinking.

Pressure is being held, but with no avail. She never mentioned being hemophilliac during the assessment. I like the DDXs on this patient so far, very good thinking. I also agree with her aggressively dying on you. But I do have one concern with giving vasopressors for this patient. On the vasopressor issue if you look at the vascular system as a milk jug; in this scenario it is the lack of fluid not the size of the container. You already perfuse bleeding that hasn't had any signs of slowing down and signs of internal bleeding. Remember a big contraindication to vasopressors is hypovolemia. She is definately showing the signs and symptoms of hypovolemia which would make vasopressors contraindicated on this patient. (Not being a know it all or smart alec here just stating some food for thought). So you are giving a fluid resuscitation. Things get busy and that's understandable. I'm glad you revisted it, things have changed a little since you have been gone. I understand the pharmacology aspect of EMT-B class, barely any knowledge due to always wanting to call for ALS on the bad major calls. You are running code run. Still got 20 minutes to the hosptial. We all miss things, keep on trucking I am liking what I am reading so far. What is making you all think septic shock on this patient? I am curious? Well during transport you are now hearing gurgling coming from her airway. You open her airway and find blood filling up her mouth. You also have her on the heart monitor and are now seeing the occasional PVCs becoming more and more common as time goes on.

Her abdomen is distended throughout it in the entirety. As you get her to stand she goes unresponsive and falls back into her chair and does not regain consciousness. Her airway is patent and open at this time, her breathing is 22 bpm and regular, pulse of 170 weak in carotid, no radial. The pressure bandage is still bleeding through steadily. You also notice blood now coming from around the IV itself. You start your fluids infusing now. She is on O2 and you are transporting with Nypamedic with the patient in the condition above. The only Hx for abdominal trauma is after her car acciden that caused the abrupto plancentae. (she say Does it? Plavix and ASA are only antiplatelets which means they would resist the agreggation of platelets but would allow for some clotting over time. You have been fighting a bleed for over 15 minutes without signs of any clotting. She is on the 15 lpm NRB. She is in the modified trendelenburg as well. Cardiac monitor shows a rate of 170 with occasional PVCs. Where do you go from here? (sorry for the backwards responses I dunno how they got that screwed up.)

Her rash has been developing slowly over the past couple of weeks along with the aches and pains she has been having. Her hand is still bleeding pretty good even with direct pressure, it saturates the gauze you are holding. She has not gone to her doctor yet for a check up, she has that next week but figured something was wrong when her hand wouldn't stop bleeding. I like the possibilitty of toxic shock, it is very possible with this patient. Her abdomen is distended and rigid has a board of wood. You also notice the strange black rash on it as well, along with ecchymosis. No palpable masses noted, she is still having some vaginal bleeding but her doctor said that it woud be normal after a D&C. No other bleeding is noted at this time. And her doctor didn't say whether or not to take them. She has a family history of heart problems including heart attack so her doctor put her on plavix and ASA to act as prophylaxis. I would agree with your load and go status; as either a BLS or ALS provider. You have already requested ALS care and they were 15 minutes away 10 minutes ago. They are coming from the direction of the hosptial and can meet you en route. You have about a 25 minute transport running emergency lights and sirens to the nearest hospital. The whirly bird is out on another call right now and won't be back in time to pick your patient up. Keep going you are doing well, How do you want to move her? What else would you like before you leave? You have been on scene about 15 minutes at this point and you took those vitals right when you first walked in.

Great pickup and good catch! Keep posting I would like to get alot of different opinions on it. Haha thats one I haven't heard yet.

The rash is not raised but looks to be coming from below the skin, it is dark black and cannot be blanched off. (not much help probably but I will give you the answer once the scenario finishes.) Do you want 1 IV or 2? What gauge? Fluid? How much O2? and How would you like your patient moved?

Sorry about that I mispoke, it was on her hand, not her arm I apologize. She states that she has been on the medication for a couple of years and that she hasn't stopped taking it since it was prescribed. She gets slightly emotional about the miscarriage but does not get over upset. Her reaction is what you expect after something like that. She states she is keeping herself busy by working and doing her normal routine. She shows no signs of depression that you can tell and denies being depressed. She is in high spirits throughout the conversation. She shows signs of worrying and anxiety about the bleeding and the pain. (By the way the pressure bandage on her hand that we placed has become saturated as well, in case someone missed that in a before post. Good discussion and assessments so far. So what's next?

Already, increased BSI is now on, along with your eye protection, horatio. Negative on fever or nausea. Edited to add more information.

Not a problem, check on scene safe/BSI, no threats to your welfare are found or suspected. House neatly kept, she is clothed appropriately for the season and appears to be of no threat and no pill bottles are noted in the foyer. Lung sounds are clelar, pressure is double checked and is as listed. ALS is en route to your location to intercept (if you are not already a medic). Towel is saturated, and your pressure bandage is now saturated completely as well. Laceration is approximately 2 inches long and not deep at all, just bleeding profusely. No other bleeding is noted. Pain is in the abdomen and it is diffused throughout the abdomen, although she has aches and pains all over her body. The rash looks black, not burns and it is throughout her arms and face. She tells you that the rash is all over her body. No loss of consciousness, and she had a car accident three weeks ago that caused the seatbelt to cause an abrupto placentae. She was discharged a week later. Do you want to wait for ALS to get there or do you want to intercept en route, sicne they are en route to your location now? They are 15 minutes away and your nearnest hospital is 25 minutes away.

Oh I wouldn't back out just yet. Alright, so your thinking hypovolemia due to paleness. Well you apply a pressure bandage, it appears controlled. You go ahead and get SAMPLE and OPQRST S- Bleeding, rash, and abdominal pain A- NKDA M- ASA, Plavix P- She has a family history of heart disease and the doctor put her on meds as prophylaxis, Previously pregnant X 3 weeks ago. Lost child after a gestational period of 11 weeks. L- Bacon, egg, and cheese biscuit this morning, was making lunch when she cut herself. E- Pain has been going on for about 2-3 weeks, worsening over time. O- Bleeding started after she cut herself while cooking. P- Pressure seems to control bleeding. Q- Abdominal pain is a constant pressure feeling. R- Aches throughout the body, but mostly in the abdomen. S- 9/10 T- 10 minutes ago. The rash is not burns, it is different than what you have seen before. Her vitals are as follows: Pulse- 140, BP- 80/40, Respirations- 20 shallow, BGL- 110, SpO2- 98. Continue on assessing, You are getting close, but before you jump into your treatment plans get a full view of the picture. I like the treatment plans you have shown me so far for various things, but tunnel vision can kill your patient if you are not careful. Also from what I have heard, raising the extremity in the air has been taken out of standard practice. (I will do research to verify that though).

She does watch you, No signs of an altercation, She is bleeding from her arm, she is slightly bent over. Look below for the full general impression. Nothing unusual, Your patient tracks you through the room and acknowledges your presence. You find your patient pale with a strange black rash throughout her arms. She is clothed in a T shirt and blue jeans, she also has the rash on her face. She is holding a towel that is saturated in blood on her arm. She states that she cut herself cooking and it refuses to stop bleeding and her abdomen is hurting terribly You are "the" lead on this call, just because you don't have a medic don't mean you don't know how to run it. You are an EMT where i come from that is pretty much the highest level of care. (i'm from a rural area with a county of less than 15 ALS providers.) You can call for ALS intercept if you need them. Keep your treatmetn going from there, I'm a EMT-B working on my Paramedic right now so I will be interested to see your treatment plan. PD has arrived and declared the scene safe. No one else is in the house and there is no other signs of trauma except for the cut that she has already told you about. You are cleared to start assessing.

My preceptors have made me in clinical calculate drip rates for the drips we start after the doctor has ordered them. When I am back home working I have at least a 45 minute ETA to the closest hospital. Most times it is longer than that. I have always had trouble with dopamine calculations so I thought that I would start this post to see what people thought about it and possibly help someone out in the long run. (The hospital I did my clinicals at had pumps we used for drips but our preceptors wanted to challenge us because we don't have pumps in our units where I'm doing my externs). I am 2 and a half hours away from my hometown for college. Where I am now I am only around 15 minutes or so from the hospital.