FireEMT2009

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

What's the 12 lead say?

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What performance enhancing (legal) stuff has he been taking?

Is he doing a metabolic cleanse? Is he doing the niacin cleanse? Do you see any niacin or supplements on the bedstand or the bathroom?

With the URI, has he been taking anything like benadryl?

Did he take Ectasy

Sounds to me like he is having some sort of thermoregulatory event

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.

ok scenne safe

lets start PQRST?

Vitals?

O2 therapy

ECG....any abnormailities?

with this information we can go on and determine course of action

Where in the house is he?

Anything around to suggest what might be causing his problem e.g. gas left on, empty pill bottles, meth pipes?

General physical state?

How grossly unwell does he look?

Observations?

Any signs or symptoms of chronic or acute cardiorespiratory disease or dysfunction?

I wouldn't put him on O2 unless his SPO₂ is < 98%; oxygen is not a "general" treatment nor it is a treatment for tachypnea

question mark was left of the o2 line kiwi

however it is chest pain, with out any know cause as yet so it is not a 'general treatment' as yet

and we do not have any vitals as yet so how do we know if the pt has any tachypnea? he has SOB. I can be SOB and breathing at 12 - 16 resps/ min

I wasn't getting a dig at you mate, but it is my absolute damn near #1 pet hate when people slap somebody on oxygen "just because" without any consideration if they need it or not. There is good evidence that supra physiologic amounts of oxygen make outcomes worse for MI and stroke patients.

I'm hearing CP and SOB, I'm thinking oxygen as a POSSIBLE treatment. It's what's indicated in protocol. It may not be indicated when I actually get eyes on the patient. We'll see. But if it's not high up in my brain, I'm doin' it wrong...

Waiting for more patient info at this point.

Wendy

CO EMT-B

ABC's PQRST, medical history, How is he positioned, sitting up, tripod position, laying down supine, on side. Skin, dry, wet, cold warm, cap refill? When did this start, what were pt's activities prior to onset of chest pain and sob. My protocols say sob gets o2 non rebreather.

What Craig said plus SAMPLE.I'm especially interested in medications, prescription, OTC, or illicit.

Around here we treat the patient, not the machine. In my books (and not my protocol book) any SOB is an indication for O2 therapy with a NC at least, the pulse oximeter could be getting an erroneous reading.

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.

I must say this is a bad to the bone scenario. This thread has been very entertaining and educational. Very well run. You did not hide any details or spring new and obscure symptoms midstream. Scary as all get out. The kind of calls dreams are made of, bad dreams.

I had never heard of DIC before but am all over reading up on it now.

Can Toxic Shock present without fever?

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.

Fire - the status is based on post counts. I'm not sure where each cutoff is exactly, I just know that after 1,000 posts I became an "Elite" member - whoo hooo...

Don't let that encourage you to pad your posts however. Make thoughtful, informative postings, stay active and before you know it, your status will change to reflect that.

... or ... just buy a subscription....

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

It sounds like you are enrolled in a top quality Paramedicine program !

The really bad part about this call is how far behind the curve the Pt was when EMS was called. She was de-compensating and had already passed over the downhill threshold. The fluid challenge's and massive doses of platelets and packed RBC's might reverse the syndrome. But it sounds like this might not of had a good outcome.

Great scenario and presentation 2009.

Now I'll toddle back to my park bench and let the kids play some more. :-}

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.

I must say this is a bad to the bone scenario. This thread has been very entertaining and educational. Very well run. You did not hide any details or spring new and obscure symptoms midstream. Scary as all get out. The kind of calls dreams are made of, bad dreams.

I had never heard of DIC before but am all over reading up on it now.

Can Toxic Shock present without fever?

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.

What is DIC?

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?

Begin suction with a French tip. I would consider modifying the tip with a naso-gastric tube so I could suction deep into the bronchi through though ETT. I would keep an eye on the SPO2 and ventilate and suction intermittently as needed. Make sure goggle strap is tight and face mask is pulled up. Put on a face shield if available.

In the mean time my medic does all that cool stuff you do with the meds.

We have a policeman or someone driving our ambulance.

Your patient now has an ETT in place confirmed correctly by condensation in the tube, capnography, breath sounds, and espoghageal dectector.

I'm wonder if after the trauma induced abrutio and D&C if they did an ultrasound of abdomen.

Lack of clotting factors and other S&S make me wonder about Splenic damage. I do agree with the DIC diagnosis. The "rash is a good indication of that.

The earlier post about the two anticoagulants prescribed was meant to point some of those that were not getting the why she was bleeding profusely.

She is a pt that is certainly circling the drain and in dire need of resuscitation by any & all means available NOW!

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.

OK, thanks for the input on vasopressors, please take this in the spirit it is intended.

Hypovolemia is a RELATIVE contraindication...refractory hypovolemia is not. In other words, it is perfectly appropriate to to do vasopressors and fluids simultaneously or after fluids or other efforts have failed. This is common practice in most any large IICU setting, especially in the treatment of DIC and septic shock. A good friend of mine recently had a young 20s female with DIC and septic shock on a CCT transport ...14 drips (3 pressors) and in excess of 8 liters of fluid.....in the first day.

SO, I would do still do BOTH.

2- I am confused by the gurgling bloody airway...is this around my tube, or are you simply stating I have justification to intubate...because I had justification 30 seconds into this call ( "Anticipated clinical course").

RE: Septic Shock: Why do I think this is a possibility?

• Recent surgical procedure (D&C ) gone wrong leading to septic shock and peritonitis...
  
• OR micro emboli from the D&C showering the gut (i.e. intestines) and causing necrotic Bowell and peritonitis (this is my personal bet)...
  
• OR a previously undisclosed reason (Tampon in too long, Rough sex with a paramedic, who knows? Where is Dr. House when you need him)...
  

To those who believe it is simple over medication and /or traumatic rupture....Yes Yes it could be simple bleeding but if it was a traumatic rupture it would have happened a long time ago....in the first week post MVC or after the D&C and either cause would have killed her quicker. In this stage, finding out the why is secondary to keeping her alive long enough to make use of the information .

The rigid painful ABD in the absence of recent trauma with the DIC and the rash/SQ hemorrhagic discoloration strongly implies septic shock the other s/s and shock ---->DIC with SEPTIC SHOCK.

Excellent comments man, really. Ketamine is not as common over here as it is over there for RSI... Dont ask why ..... there is no clear reason other than an abuse stigma. I agree it would be the better option than Etomidate.

As for Etomidate in sepsis.. clearly it is dose dependent and to a lessor degree age dependent....but every time one study shows it is a big deal, another one shows something different. Lets agree its a consideration and a judgement call neither right nor wrong but depending on what else you have to work with.

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.

Is she a hemopheliac? or have some other type of blood disorder that will not allow her blood to clot? The ASA and Plavix she has been taking could very well make that kind of disorder even worse. Since she is now unresponsive how do we know that the only trauma was the accident? I would start another line with ringers and run it wide open.

I would also have DFIB hold pressure on the cut...( we are already covered in her blood, a little more wont make a difference) Notify medical control of what we have, whats been done to this point and advice on what to do next. I would also be ready to intubate and support her completely as well as CPR if needed.

Oh yeah...she gets a diesel bolus as well but we are missing something....I just cant quite figure out what.

Pressure is being held, but with no avail. She never mentioned being hemophilliac during the assessment.

VERY IMPORTANT POINT: Absense of fever does not preclude an infectious process or septicemia.

Now I am going to ramble. If you want to skip ahead to treatment, feel fee to do so.

If this was without the precceding history and if her mentation was more altered with neuropathic-encephalopathic s/s ...... I would think septic shock secondary to meningitis. She is the right age for that kind of silliness...

HOWEVER, Since there is no suppotive history for meningitis, and SHE DOES HAVE the history of abdominal injury, miscariage, presumptively for a D&C, and abd rigidty, I am assuming probably some adverse sequala from the abrupted placenta/D&C, and related care. (I am assuming she isnt a closet alcoholic with end stage liver failure and coagulapathy, right? )

My guess is that she is currently in DIC, and probably secondary to septic shock, with exacerbating coagulopathy caused by her plavix/ASA a (distant) second in my mind.

Regardless, the exact etiology is academic at this point At this point she is actively (strike that...AGRESSIVELY) dying. The cut on the arm probably saved her life because it prompted the call for help.

So, to recap treatment and add some:

BLS:

O2, BVM, OPA, Suction PRN, Shock position, and the TQ on the arm lac is a good idea. If you are one of those agencies that carries hemostatic agents, use them.

A special comment on the TQ: Use a B/P cuff not a CAT or similar TQ. In this case a narrower TQ (like the CAT) may actually precipitate severe bleeding at the site of the TQ due to micro-lacerations in an already coagulopathic patient.

ALS:

1- ETT placement, va RSI/MAI if required, but do not use ETOMIDATE (mixed research on its adverse effects on adrenal response and survival in septic shock situations)

2- 2 large bore IV's, Start significant fluid resuscitation. I know there is a lot of information about permissive hypotension, but 99% of that is in traumatic cases. In SEPTIC shock, and in DIC, restoring perfusion to the gut and kidneys is paramount, and fluid resuscitation is key. Therefore, I would open the lines up and reassess Q 500-1000cc but probably wouldn’t slow down until I got past 2 liters.

3- Start the vasopressors now concurrently with your crystalloid infusions. Again I am presuming DIC secondary to septic shock, but in this case EPI drips (2-10 mcg/.min...mix 1 mg in 250 cc) is going to be a better than dopamine, though you may have to do both. if you carry levophed, that is probably your best choice.

4- When/if you get some breathing room...Since she is going to get multiple lines, start a third. YES a THIRD line. Use a twin cath (multi lumen) because many of the meds she needs to get NOW are not compatible with each other. Start it now while she has some vasculature left to hit. Yes she is probably getting a swan and a multi-lumen central line later...but only if she lives that long.

Some thoughts: CHF is not an immediate concern, you have PPV in place which will stave off any pulmonary edema. In most other 20-something-year-olds their cardiovasculature can take 2-4 liters with no problem. Since we don’t have a lot of history on her non-specific cardiac issues, we cant assume that is the case with her, but we do KNOW she is dying right in front of us. If we dont start large volume resuscitation concurrently with vasopressors, she wont live long enough to die from CHF.

One more thought: Yes this looks like DIC/MODS and possibly septic shock as I described above, but the only time I have seen septic shock try to kill someone this quick with (presumably) this sudden onset of DIC is bacterial meningitis, and I have heard that same thought repeated by several well respected docs in my area. THEREFORE: While none of the history points to this, It costs nothing to mask up all providers as well, and use the HEPA filters on the vent. Cover all your bases.

One final thought: If she doesnt code, andshe doesnt respond to dopamine, epi, and volume rescusitation, I would get orders (or in my SWO's..invoke a clause that allows me todo this without calling due to her trying to die right in front of me... ) to increase her Dopamine beyond 20/mcg/min to about 30 mcg/kg/min...at this dose it mimics (kinda) Levophed.

Unless I carry levophed, which most services do not. At this point, your pulling out all the "stops".

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.

Sorry I didn't get to revisit this thread yesterday. I was sitting in the county courthouse waiting for my turn to be one of the 12 angry men, and spent 8 hours in a lobby for $25. Not that I'm not used to sitting around for long, extended amounts of time with nothing to do, I'm just not used to doing it with 200 others.

In any case, I quoted DFIB because given the evidence from page 2, that's exactly how I would have handled the call. After you described the "rash", which sounds like a SubQ bleed (large subdermal hematoma, maybe), and then I was gently reminded of the ASA and Plavix, the light bulb came on. Sadly, I don't know how many of my classmates would pick up on that aspect, because our pharmacology section was dreadfully short ("This is oral glucose, this is oxygen, this is an epi-pen, this is an inhaler. Any questions?").

Regardless, I would try for the ALS intercept but otherwise lights and siren, 80mph to the nearest facility. Pt supine or in Trendelenburg, recheck vitals after loading, then every 5 minutes. O2 via NRB if tolerated. Tourniquet the arm, then hope the traffic gods play nice with us on the way. St Diesel, pray for us.

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.

I should have jumped on the toxic shock/septicemia idea when it was first mentioned but the absence of fever derailed me. Darn, shoot dadnabit, doggonit and any other exclamation you wish to insert.

If this is the case the patient is buggered before the call went out.

Hemophilia discriminates against women but her clotting ability is definitely done. I wonder if runing a PTT would help at this juncture? Just kidding.

I missed the no fever thing as well....dammit!!!! I mean I read it but it didn't click. Grrrrrr!!!!

We all miss things, keep on trucking I am liking what I am reading so far.

Good call, Croaker. I concur with everything you said. DIC possibly from an incomplete abortion or even just the miscarriage ietself with full on septic shock.

Absence of fever does not rule out septicemia. If you have an abnormally low white count which happens rather than a high one you don't necessarily get the fever you expect to see.

Aggressive fluid resuscitation (meaning more than 2 liters as fast as possible on a pressure bag) with inotropic support is your only chance of saving her. I can see her getting liters of fluid along with blood products in a very short period of time.

The onset was not so rapid as it has been coming for days. She is just at the complete decompensation stage and has nothing left to compensate with. If her rash is that advanced she may already be too late to save.

She needs antibiotics and blood products fast along with some clotting factors.

Definitely ALS intercept if there is any length of time to the hospital. Not only for securing the airway but because you are going to need a couple of sets of hands to push fluids, start inotropes, etc. Might want to check a glucose level as well on the way but not the highest priority.

Sorry, I'm just rambling a bit because my brain is in all sorts of time zones right now!

She needs her airway secured to take control of her breathing as well. If you only have Etomidate I would still use it as you can give a shot of steroids later but Ketamine might be better if available as it can give you a slight boost in hemodynamics as well.

Of course if she is completely out you hopefully won't need anything to assist with intubation. If she has no gag just tube... You can't afford to give her any kind of medication that will affect her hemodynamics as she is already crashing and anything that takes away further from that catecholamine drive is only going to put her into full arrest faster.

What is making you all think septic shock on this patient? I am curious?

I would look at alternatives over etomidate still. THe steroid "solution" has all sorts of problems too. If I had nothing else I would consider a benzo, she probably doesnt need much of a push to take her down anyway...though you are absolutely right on the hemodnamic concerns.

Its really a choice of the lesser of two evils...

Or ..as they said in Master and Commander....

The lesser of two weevils!

3 points for the obscure movie reference!

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.

After 2-3 weeks the vaginal bleeding should have stopped by now. The car accident involved abdominal trauma that caused the miscarriage. What quadrant is her belly distended and rigid? Lower quadrants I would guess a perforated uterus because of the D and C. If the impact from the accident was enough to cause abruptio placentae,she could also have a ruptured uterus that they didn't catch earlier or made worse because of the D and C.

I'm not sure about the TQ. I would use it as a very last resort, if additional dressings and pressure didn't get the bleeding to stop. I would also would not be hosing fluid in. Giving the 250 mL bolus should be enough to bring her pressure up but she is already starting to decompensate and ringers or saline don't carry oxygen, so I would be careful about that.

It's pretty obvious that we are behind the 8 ball with her.

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.

Since Terri is meeting me in 5 minutes we are going to be ok.

I would get a tourniquet on arm to stop the bleeding which is more obvious now because every drip is one I will have to get out of my ambulance.

I would transport supine because my patient is A&O and change to a trendelemburg if her alertness and general impression deteriorate. I would medicate her with O2 according to her SPO2 reading via a non rebreather mask. My driver will travel with lights and siren. I suspect an serious abdominal internal bleed that could be stem from several reasons.

It could be a spontaneous bleed that developed post-partum that is aggravated by anticoagulants. She could have a perforated uterus post D&C.

She could still have and incomplete placental birth. I am leaning toward the first.

Has she had any kind of abdominal trauma?.

Since it has been 15 minutes I need another set of vitals.

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

With the ASA and Plavix, that explains why the cut wont top bleeding. Put another pressure dressing on it. I am also guessing that the rash is a subq bleed. Oxygen at 15 liters by NRM. Get her on the stretcher and into the ambulance. Start an IV of ringers, draw bloods (if you have it) or saline, I would also put iher in modified trendelenburg and give her a 250mL bolus, then cut it back to KVO and reassess BP. Cardiac monitor. With the ASA and Plavix, her INR may be too high.

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.)

You are correct.

I have to stop the bleeding first. Add an additional compress and increase direct pressure.

Ask how long she has had the rash. Ask if it has been diagnosed before and if she is taking anything for it.

Why is she taking Plavix and ASA after having an abortion?

Did she have a dilation and curettage done after her abortion?

Surprised she doesn’t have fever otherwise I would be very suspect of Toxic shock to me but without fever possibly internal bleeding

Is her abdomen hard? Is there any guarding? Does her abdominal pain radiate?

Are there any palpable abdomninal masses that have a pulse?

Does she have any bleeding in her eyes or other mucous tissue?

Does she have any vaginal bleeding?

As a EMT-B Regardless of finds she is going to be a load and go.

What is my transport time to decide if I need an ALS intercept or even a Helo for transport/

Revisiting the vitals I say she is in decompensated hypovolemic shock or very close to it. She needs at least two large bore IVs quick. What is quicker an ALS intercept or the transport to the hospital? Do ALS units carry albumin?

Oh, I am guessing the rash is not a rash at all but a subcutaneous bleed.

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.

HINT: She's on ASA & PLAVIX

now I'll go back to the old folks park and watch the kids play

Great pickup and good catch! Keep posting I would like to get alot of different opinions on it.

Hey silence you.... I think she has the plague!!

Haha thats one I haven't heard yet.

Would like to know more about the rash. Is it a palpable rash? or more like petichiae?

How long has she had it?

Does it blanch?

Lets get her on the cot and put on a little 02 and start an I.V.

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?

ok...so she is shocky with an elevated pulse and low BP. Car accident that caused a miscarriage, 3 wks ago, and abdominal pain since. How did she cut her arm while cooking? most people cut thier hand or fingers...not thier arm...just sayin.

The rash is kind of strange. Medication reaction maybe? Is she depressed because of the miscarriage? Does she meet your gaze when speaking to her? Does she have a flat affect? ie: no show of emotion.

Something is off with the whole cut on the arm thing. Where is the cut located?

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?

Fever? Nausea?

Back the f up! I am putting on a gown... and maybe another pair of gloves! of course I always wear eye protection too.....

mostly because my Oakley's look frickin cool

Already, increased BSI is now on, along with your eye protection, horatio.

Negative on fever or nausea.

Edited to add more information.

Forgive me if I repeat, been too long since I've jumped in on a scenario. First and foremost.. BSI. Scene safety. Dogs? Anything/anyone that could possibly hurt me or my partner? What's around her? Pill bottles? Anything that could possibly be perceived as a weapon? Clean home? A total wreck? Lung sounds? Double check the pressure to make sure. She's getting shocky. Plan to treat accordingly. I personally would be calling for an ALS intercept. Fluids aren't gonna hurt her at this point. Blood? How much? Where? On the clothes? Floor? Do we know how big of a laceration? Any bleeding noted from anywhere else? Where is the location of the pain? The entire abdomen? Any specific quadrant? What's the rash look like? Blisters? Open sores? How long has she had the rash? Are the bandages still controlling the bleeding? Any loss of consciousness PTA? Do we know what caused the miscarriage? At this point most of my questions are going to be answered en route. Load and go situation. Plan to meet ALS en route. If no ALS, high flow oxygen high flow diesel. Treat for shock. Maintain... Maintain... Maintain.

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.

I would love to go ahead and run with this scenario but I'm going to wait for some more responses from basic providers

Oh I wouldn't back out just yet.

If she's pale, I'm going to make the assumption that she's lost a lot of blood. I can't really place the "strange rash" except for maybe burns. My treatment is as follows:

Direct pressure (along with elevating the wound) to stop the bleeding, tourniquet as needed. Dress and bandage. Prepare the patient for transport. O2 via NRB @12L (seems like she's lost a lot of blood if she's pale, O2 probably won't hurt at this point). Watch for signs of respiratory distress in case it is a burn (airway compromised).

Vitals and Hx in the truck on the way to the nearest facility. Probably run a Priority 2 unless she has really poopy vitals, or starts losing going unconscious, then Priority 1.

Just for giggles, what are her vitals? BP, Resp, Pulse, SPO2?

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).

What does the house look like? Does it look like there's been an altercation? Is the patient alone in the house? Get a quick run down of what's going on. Where is the pain? Where is she bleeding from? How does the patient present? Is she doubled over? Sitting Up? Does she watch me come in the door? Any physical signs of trauma? Until those questions are answered I don't take a step further inside the door and am prepared to back out and wait for PD.

Too many variables to just go barging in on this one.

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.

I'd be nervous about entering a scene like that, but that's because I'm new.

So, I'll treat it like I'm new (bear in mind, I'm a basic. Certified as of today, but not licensed/ registered as of yet).

Scene safety, are my spidey senses tingling that something isn't right?

General impression; how does my patient look as I approach? Is she tracking me visually? Does she acknowledge my presence? Skin tone? Posture? Do I see any blood? Any evidence of trauma?

Making the assumption that this is a normal patient, I would probably begin taking vitals while my lead does the questioning. BP, Resp (rate,regularity, quality), Pulse (rate, regularity, quality), pupils, cap refill?

Regardless of findings, I would probably load her into the truck, hook up some O2 @12L via NRB, and head for the hospital, conducting my detailed physical exam and ongoing exam en-route. My findings would just determine how fast I would have my partner drive.

So... how'd I do? I'll be back to read the Paramedic response to the situation later.

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.

Except for those rare folks that have pumps it's always 'spit balled' though, right?

Brother where you do work as a volly EMT/medic student that you're setting up these kinds of drips, particularly Dopamine?

Dwayne

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.

Yea if im setting up a med drip i use the Dosage needed to be given, times, drop set, divided by concentration like you stated earlier. I use my calculator usually so my drops are correct because I have alot of trouble working with big numbers in my head, and usually if I'm doing a drip like dopamine I don't have time to get a piece of paper and pencil to write it out.

You are dispatched to a patient with abdominal pain, with bleeding. You arrive to find a one story house with one car in the yard. You knock on the door announcing that you are EMS and here to help.

She hollars that the door is open and to come on in. You arrive at the patient, a 37 year old caucasian female, in the foyer of the house sitting down in a chair.

Go from here...