FireEMT2009

Imma go old school here but, here it goes. Airway? is it patent? Breathing?- RR, Lung sounds, depth and quality? Circulation- Pulse, strength quality and regularity, major bleeds perfusion? Place the patient on a nonrebreather 15 lpm Reassess vitals do full workup, pupils, skin tenting, grips, can i get a temperature in farinheit please? im not good in celsius, EKG followed by 12 lead, BGL, stroke test also get a good look over of the vehicles, such as pill bottles, wallet with a file of life, medical id braclelets, any information that can lead you to any kind of conclusion. Rapid transport with two IVs running on TKO for now just in case

Small geriatric female. I would not call her thin or frail. No previous respiratory problems just the mitral valve replacement, hypertension, and diabetes. What would your treatment plan and DDx be?

I didn't know that, interesting. You have administered the nitro. Yes the lung sounds were clear and remain clear. You have a line in place. Her BP is now 124/86 HR- 120 RR 24 still labored SpO2- 98 serial 12 leads still show no ectopy. I like your DDx. Are you en route to the hospital yet?

Her BGL is 120. We do not have a ETCO2 at this time. She was not arguing with the husband and stated by her and her husband they were just watching TV and eating breakfast. Patient does not look scared or nervous. Upon impression and inspection you find no evidence of physical abuse or psychological/mental abuse. You are about 10 minutes outside of the nearest hospital. Why would you want ot trial glucagon for a patient having SOB? You have given 324mg ASA. She states that her SOB is slightly reduced with the application of oxygen. What other treatments would you like. Are you ready to start hitting the road?

I think she might have been on a ASA regimine actually. Sorry about the red herring, I am having to run this based soley off recollection.

She states that it is hard to describe. She said its constant and it isnt musculoskeletal. It cannot be reproduced by palpation.

Exam shows no reddened or inflammed areas. She has not and any type of pain recently except the shortness of breath. She says she sits for about an hour but gets up and does other stuff,. so no, not long enough to cause clots to form. and family history is unavailable.

No history of PE or blood clots. She takes no blood thinners. She was only in the chair for about 20-40 minutes while eating breakfast with her husband while watching tv. That is a good field impression. What are some other DDX for this patient?

Bieber, 12 lead comes back completely normal. The pain is in the her chest she really cant describe where it is or anything. Oxygen made it little better. The pain has stayed the same. Insulin is her only medication and no known allergies. This has never happened to her before. She also states that she had a mitral valve replacement about 8-10 years ago. HEENT: Nothing remarkable. Neck: Nothing remarkable. Abdomen: soft nontender. Pelvis: stable. Posterior: nothing noted. Extremities: Nothing remarkable. Pain level- 4-5 BGL-130 15 lpm NC? Do you mean 5 lpm? You now have an IV running TKO. Sitting in a chair watching tv. She stood up and the pain started. Ngetative on pain. and she has stated that it pretty much stays the same.

Nice house, yard cut, clean, spotless. Scene is safe as possible. Extreme trouble breathing, really working on breathing. No audious breath sounds heard upon meeting the patient. Nothing coming out of her mouth. Skin is normal. PPE- gloves are on, face masks are standing by just in case. She was standing but you had her sit down on the steps of the stairs to do your assessment. She had to walk down a flight or two of steps to get to the door. She is alert and orientedX4, tightness in her chest, clear breath sounds, IDDM and HTN, Started earlier when she stood up out of a chair. It started 10-15 minutes prior to your arrival. BP- 146/94 SpO2- 95% on Room Air HR- 100 regular strong in radial. RR- 26 deep, labored. EtCO2- unavalable. 3 lead EKG- Shows sinus tachycardia at a rate of 100.

You are dispatched to a house for a patient having trouble breathing,her husband and her have meet you at the door. She is having obvious difficuluty breathing. You get her to stand on the stairs behind her. Treat her! FireEMT2009

Thanks! I will definately be sharing another one here shortly!

That is what I was thinking. We have the IVs in already, im saying be ready because his pressure could start to bottom any minute since be is bleeding like hell. The thing that I would say I dont agree with you on with your treatment plan is trying to pack the wound in his mouth. We need to try and stop the wound but being in the mouth it endangers the airway by trying to pack the wound. If I have misunderstood what you meant by packing it please correct me. Hopefully this patient doesn't crash till we can get to the hospital. FireEMT2009

Dwayne, Our paramedic school and the standards themselves state now that 90 is where we should aim our BPs to be at in patients that are hypovolemic and need fluids. That is the rationale I'm guessing he used when he chose that number. FireEMT2009

You drop another 750 mL, and he starts to groan. His blood pressure is now 89/60. You administer another 250 mL and he comes around and starts to wonder what happened and who you are. You are now at the hosptial and the ER docs and nurses have been handed care. The doctor comes in later and stated that your patient stated that he had been working in the factory and he got sprayed with the dispenser accidenty. He said he wiped off as much as he could.but still had it all over him. He went home that night and started having horrible diarrhea and vomiting. He just thought he was haivng a horrible stomach flu. The doctor stated that he had suffered severe dehydration along with the organophosphate poisoning. Doctor shakes your hand and congraduates you on your save. Congrats Beiber for working all the way thorugh the scenario! Thank you Dwayne and everyone else who commented.

Dwayne, If you go intubation route you might want to try and premedicate the patient with lidocaine first. It is thought to help decrease ICP. which could be a major issue with him.

Well I am going to keep the blanket on him anyway because since he is bleeding in copious amounts and the rigidity in the stomach and the dropping BP means that he will become susceptable to hypovolemic shock and will become easily hypothermic. I am also gonna get another set of vitals. FireEMT2009

After initial bolus BP and pressure change, others stay the same. BP- 72/48 HR- 120. After initial bolus BP and pressure change, others stay the same. BP- 72/48 HR- 120. Aflac pays you money!

Beiber, His secreations have officially stopped with the administration of the 2mg. His wallet and phone was found in his clothes. Your crew walks in with a biohazard bag and collects the clothes on the floor. They state his floor and bed were all covered in this white looking powder, the same looking powder that are on his uniforms that were in the pile. The neighbor has no further information. You call the plant he works for and they tell you that he has been out the past two days with a real bad stomach bug. They tell you that he works in the pesticide department pouring a powder pesticide into the bags. Remember beiber the time is 2200. You find no ashtrays or cigarettes/lighters. His BGL is 130, and still unconscious.You find a number for a person named "Mom". You call and she tells you that he is only allergic to penicillin and milk. She also tells you that he has never been out of the state in his whole life. She also states that his age is 35 y/o. What other questions do you have? New vitals are HR- 140 RR 12 BVM SpO2- 99 BP 62/38 EDIT; for grammer and more information that is needed to continue scenario.

Beiber, Well I am definately gonnna start two 14 gauge IVs like you said. The patient seems to becoming more and more unstable and is gonna start decompensating soon due to the fact that is lower quadrants are rigid and his blood pressure has dropped over 10 points since we got the first set. I would set my lines TKO until his blood pressure really starts to fall faster. I will also do a 12 lead just to verify that he has not had a heart episode in another part of heart. I will also cover him up with a blanket to prevent hypothermia. What was the temperature outside? I would roll lights and sirens. How is my capillary refill? I would like a repeat of my vital signs every 5 minutes. Can the son give us anymore SAMPLE?

Who looked lke the dumba** that forgot the PPE and indangered all the crews around? THIS GUY!!!!! Thanks for commenting on the PPE Dwayne.

Why dont you give me a treatment plan for what you are thinking mixed in with beibers that way we can get a double medic attack on this guys condition?

I will continually suction the mouth and once the BLS crew gets here get them to take over suctioning and get another set of vitals. I also want the bypasser to give me what he knows about what happened and if he knows this guy. I am suspecting a basal skull fracture. Do I note battle signs? SInce the facial and mouth bleeding are the only ones noted I will get someone to control the bleeding on the head. Is the abdomen tender, nontender, rigid, or soft? I am going to also try and put on a nonrebreather on 15lpm if I can keep the airway open. I will also get my partner to check on the other patient in the truck if he hasn't already. How far am I away from my nearest trauma center, and if its far off, is HEMS available? Edit: I am also suspecting a spinal cord injury, possibly brown sequard syndrome. Do I note any ETOH on his breath? I will get one of my assistance to check a BGL as well. I will also get him in a C collar, backboard, and fully trauma packaged as well. How are my pupils?

Beiber, I was wondering why such a low dosage but I gotcha now. 2mg are now in and the secretions have dried up a little. Albuterol has been administered and wheezing is very very faint now. All vital signs are the same as before except for HR at SpO2 which are as follows: HR- 140 SpO2-99. What do you want next? Do you need more information? any other physical assessments you would like to do?

Beiber, Luckly for you this patient is in pajamas, but decontamination should still be taken, the patient is deconned. He is in a suburban area, no farm land, plants or anything around the house is growing, neighbor says he works all the time. She says he works at a company that makes pesticides in small amounts but he doesn't know if it is in that department. You suction his mouth deliever the atropine. 12 lead only shows sinus bradycardia. Respirations are slowed and albuterol decreases wheezing but some is stll heard. His vitals are as follows: HR -58 RR-12 BVM SpO2- 98 BP 68/32 He is still has salivation and you have to continuously suction, The diaphoresis and lacrimation is still going on strong as well. What next for this patient?