AnthonyM83

The both of you had better learn something dammit.

And Anthony, if you win the airway gauntlet a 2nd time in a row, you better give me those shears you won last time since I provided your hotel room and all that.

Haha, deal!!!

Completly true..But it still gives you nothing without a lot of Hx and some guesses..... I know patient having a resp of 30 for 25 years...without issues that are anyhow relevant for emergency medicine most of those 25 years.

On the other hand: If I (who has a normal RR of 6-8) would have a Resp of 30 something is reallllllly wrong...

Uh, that's why assessment of respirations includes more than just rate and tidal volume. Rate, Rhythm/Pattern, Effort/Quality, and Depth, combined with history

Similar to pulse Rate, Rhythm, Quality or skin Color, Temperature, Moisture, all having to be combined with history.

I don't understand how respirations are so much different? (Respirations meaning an evaluation on the different qualities of respiration, not just rate or just depth etc)

I'll be there!!!

You guys should bug the Doc to put you on a waitlist!

Seems normal to me. Patient deaths rarely bother me. If they're dead, they're not in pain and cognizant of their death. No suffering, no fear, no nothing. It's similar to not being affected when walking by a graveyard. You never knew them as conscious beings.

Seeing the family grieving for the patient, on the other hand, really bothers me. For me, it's the absolute hardest part of the job.

I will say that the longer you're with a patient and you feel like you're actions might actually affect the outcome of the patient, the more their death affects you. Even more if they were alert and oriented at the start of the call...but even then it's minor. I've taken a personal moment for different patients...usually pediatric arrests...but it's a rare exception, not the norm.

I always wonder about those cardiac arrests with confirmed asystole that come back spontaneously without any interventions other than CPR. I imagine just like other dysrhythmias, asystole can be a transient one while there's hiccup in the system, then eventually self-corrects or compensates. Luckily this guy had someone doing compressions for him during that time....

On the same note, I wonder how many times an ALS crew arrived to cardiac arrest with EMTs doing CPR, then found a pulse upon reassessment, probably assuming that the EMTs had screwed up their pulse check...

I've had a few patients with it. I think it was usually for altered or sick/fever/weak type symptoms. I wasn't lead on any of those calls, so I don't quite remember more info about it...

You feel like crap because you potentially saved his life or at least decreased his time to diagnosis by the doctor?????? You're a horrible person, indeed...

Edit: Just saw the timestamp and update. Well there you go

Copy!!!

Still don't know if I'm going to be able to go. Kind of looking like no, financially. But I'll give it a try. Was a lot of fun last time!

I had a patient who usually had the hypertension episodes intermittently maybe once a week or so. After he had a new Foley put in, he said he noticed urine leaking through, and was waiting for Monday to get to his doctor again (he was paraplegic from a GSW). Somehow the Foley problems were causing episodes of the dysreflexia every few minutes (way more frequently than usual, for him).

He had one of the episodes during a blood pressure check and you could see the BP rising live. Pretty crazy. It would also give him those goose bumps mentioned in the scenario during each wave of HTN. Lasted usually 2 to 3 minutes or less.

We have trauma centers left and right, so took him to one, non-emergent, figuring those docs would be more familiar with his disorder.

Why was the colonoscopy being done in the first place?

What symptoms was he experiencing?

Did he have a pre-existing wound/lesion in the perioneal space?

Gonna try to make it!!!

It's a really legit workshop guys!

Quality of life cannot be judged by someone and then used to decide whether to make attempts at resuscitation...ESPECIALLY by some guy with less hours of training than a beauty school graduate (cosmologist).

Each workup on someone who would not survive is training for when I run a code on someone who does have a good chance.

Code saves don't define you as paramedics, but preserving life is a big thing for us. Most calls with critical patients, we don't know whether they're going to die or not. In a code, they already did die, so it's already "confirmed" so to speak that this patient is "critical". If that makes sense.

Now don't go crazy and work up every single cardiac arrest, but if you've got something to work with, go with it. There's a difference between finding someone in asystole versus having a momentary asystole in the middle of a code with possible recent downtime with good CPR from your team (like in bus stop scenario).

BUT either way, judgment on quality of life gets to be a choice the patient makes, not us, sorry.

50 minutes into the arrest......well not my problem, as there would be no way I would be on scene by then...either he was dead or he is at hospital and its the doctors problem now........

some senarios can be made too difficult....

Different responses to these rhythms can't possibly be "too difficult"....

Alright then...i was interested in your problem solving...ROSC achieved and maintained 50 minutes into code. Good CPR throughout.

You push the calcium chloride (though no sign of dialysis access)...next rhythm check you have a sinus looking PEA at 52....

So everyone's good with terminating resuscitation at this point?

No one would have the curiousity to play with the rhythms and see if you can get anything out of them? Remember, we're only 6 rounds in right now and he's been showing rhythm changes.....

Mobey. You push the bicarb...doesn't seem to help, but doesn't seem to hurt.

Hey guys. There's not going to be any magical zebra in this one, but I do want to see how you manage the code and how far you'll go with it.

So, now after your third round of EPI, you get a wide complex rhythm...looks close to V-Tach, but only at 105. No pulse..

Just seeing if anyone has any thoughts at this point....then I'll come back with next phase.

And yes, this is a mega code scenario really...

honestly it's for my own education as well to see different ideas that might pop up...I'm compressing a scenario in which there was much debate about what should have been done while the code was going...

Alright. So you set up IV access, intubate, push a round of EPI, round of AMI...on your 3rd shock, you convert to F-Fib. Unless someone wants something different here, we'll assume we continue with maxing out on AMI (300mg, then 150mg). Then 2nd shock, you shock him into asystole...what next?

In all of this, you get a head to toe done and go through H's and T's (this does take a bit to go through when you're rushing to do those other interventions in between the rhythm checks, so didn't give them to you right off the bat.

You have him intubated with CO2 at 18, well-oxygenated, no resistance, no signs of chest trauma, equal lung sounds, pupils non-reactive mid-range, no track marks, blood sugar normal range, skin warm and dry, no signs of dialysis ports..not sure if I'm forgetting one here. Basically, you get no help on the H's and T's.

He just went into asystole though on the 5th shock.

You ask the bystanders (who are staring at what's unfolding as if it were a TV show) if they saw anything...most of them startle when they realize you are addressing them and it's not a TV and you can actually see back at them...they mutter stuff in Spanish and quickly hustle off, pulling their kids away as if you were yelling at them. Typical.

AED says no shock advised. If BLS level...what would you guys do next in your area?

ALS:

EKG shows VTach. You confirm no pulse. Finish off two minutes CPR. Charge during compressions. Shock. Continue compressions.

Alright guys, gotta throw in order of interventions. Can't just say I'd intubate, start a line, physical exam and have it magically done all at once...not getting off that easy. You have an engine of 3 FF/EMTs also showing up. In addition to your EMT partner.

Holy crap, you guys jumped on this one. I like it! I had a hell of a 24 hour shift and slept all the next day. Back now.

Scene size-up:

Environment is an urban setting, evening, but still some light out. Appears safe. Regular looking people walking on sidewalk. Only patient found. Bus driver just found him slumped like that. Does not appear to need spinal immobilization. While we can't be sure, it looks like he passed out while sitting. Temperature is high 60's...normal for this area at this time of year.

Initial Impression:

Dressed in a dirty white button up short sleeve and jeans. Not quite homeless looking, but not well-kept either. Matches the part of town you're in. No smell of alcohol or urine readily evident. Appears in late 50's. 5'8, 190 lbs, slightly stout. No obvious injuries or immediate life threats as you approach.

AVPU:

No response to walking up and talking to him.

No response to loud verbal.

No response to tapping/pressure.

(Guess where this is going?)

No response to painful stimuli.

Unresponsive.

You start opening the airway, but your partner (we'll make her a hot blonde for you Kiwi) softly touches your arm and reminds you of the 2010 AHA Guidelines..... so instead you go straight to a carotid pulse check....one one thousand...two one thousands.........seven one thousand....No Pulse.

Have at it!

And yes, first guess around this area as soon as you hear the call dispatched "unconscious at a bus stop" you should be thinking either drunk...or the guy who calls daily for abdominal pain x2 years....but nope...those guys won't be calling until 3am...lucky you. You get this guy (Sorry...as much as LACoFD ship everything BLS, it's gonna be hard to "paint the picture" on your run sheet for this guy...)

You guys can be an ALS or BLS unit for this scenario, though...

Called to bus stop for approximately 50 year-old male sitting up, but slumped back on bus stop bench. You show up. Bus driver who called tells you he found him like that 5 minutes prior. No one else was around. Go.

Locally, we can give it by mouth if pt has a gag reflex. Ive been told the intent is that they are likely (not certainly) to also have a swallow reflex...so we're really giving in PO, not SL/transmembrane..... I dont know if their logic is correct, but it's one step more conservative than giving it all unresponsive suspected hypoglycemic patients ....

Good scenario Mobey.

Another thing to consider is the liability aspect. On paper, bypassing a stroke center (which might not have surgical capabilities, but must have some sort of streamlined patient transfer agreements, being as they're a stroke center and will no doubt get plenty of clots AND bleeds)...well can see a family getting upset for bypassing unless there were pretty clear signs/symptoms rather than just leaning toward a bleed based on hunch/experience/gut but without something concrete.

LA County specific