hammerpcp

I am going with my original diagnoses of peritonitis. Sz caused by all or one or a combination of the following: hypotension, hypoxia, toxins in blood from ruptured intestine, fever. Lets get the docs to look at his abdomen.

Did we ask if his abdomen is distended at all? is there any rigidity or masses?

So to recap:

4am called to residence for 12 y/o male, 60lbs, altered LOC, laboured resps, febrile w/ NVD x 3 days.

Pt found supine on bed, hot, dry flushed. Moderate respiratory distress. Opens eyes and withdraws from painful stimulus and is verbalizing innapropriate/incomp. words.

Pt has had a "stomach flu" times 3 days with NVD, diffuse abdo pain increasing on palp, hyperactive bowel sounds, decreased food intake, fever, and decreased urine output. Pt had soup for dinner and was lethargic and irritable prior to going to bed.

Side note: Why is mom trying to rouse pt at 4 am?

previously healthy, no allergies, no meds.

Initial VS:

pulse 148 weak

RR 28 laboured

BP 90/40

Sats 88%

Temp 103.2 f

BG normal (? I think)

Pupils equal and reactive but sluggish

LS?

Pt has been self administering tylenol since onset of symptoms.

NOT:

CO poisoning

trauma

drugs/alcohol

Prescription drugs

menningitis

Pt now having sz activity

autonomic hyperdysreflexia. 8)

OOoooohhhhhhhh............very funny!

Well......I am pretty much done at this point. I will transport and continue to monitor VS etc. Unless any changes enroute? Now for the bloodwork!

Alrighty then. So we are thinking either infection/sepsis/SIRS, or a toxidrome of some sort. Are there any medications in the house? It isn't your run of the mill anticholinergic or cholinergic OD in any case.

Tube size for a 12 y/o 60lb child. Probably a 6.0. 60lbs is a pretty small guy.

I don't get it. Is he watching Chinese television or something?

Continue fluid bolus, 5mg valium IV, cont to assist vents with BVM and prepare to intubate.

Find out more about 'strange' behaviour. Was he confused/irritable/irrational? What OTC meds has he been taking? Did he have pain in his abdomen at any point? Has there been any blood in his stools? Is he still vomiting even with the decreased food/fluid intake? What about urination? Any neuro deficits in extremities? Nucal rigidity?

He has an infection! Lung sounds? cough? sputum? diarrhea?

Aspiration pneumonia for 100 Alex. What is meningitis? maybe SARS. Probably septic. Peritonitis?

Oh! Rabies!

Does he have any hx?

Start some NS anyway. Does he need ventilatory support?

You guys have got to put that to music.

Since you were probably sitting behind her you can always just lean forward and breath heavily into her ear once you've run out of things to say.

I am not sure if this is what you were describing Fiznat but to do a modified 12 lead in order to get a good look at the right ventricle you move V4 to the same place but on the left side of the chest and you move V5 which becomes V8 to the back level with v6 at the midscapular line and V6 becoems V9 level with V6 as well on the left paravertebral line (on the spine). In our local protocols a modified 12 lead ECG is indicated if there is ST segment elevation in the inferior leads and/or ST segment depression in the septal leads. The modified twelve lead gives you a good picture of the distal RCA and the back of the heart.

not spell checked for my convenience.

How much does she weigh? Unless she is huge then we are carrying her out. We don’t have any fancy shmancy ATVs here anyway. The pole stretcher would work well. If she is huge we can always use the good ol' rolling sticks placed under the pt or perhaps a hard stretcher type scoop or something. Al far as the snake goes how do you know she was bitten and it isn't an open fracture? This woman may be the unluckiest person in the world. Maybe we should just leave her there to die so that she doesn't have to suffer anymore.

New DMS IV Category: Community-Acquired Caproseptideontitis, Asymptomatic [CACA] - Inflammation of fecally toxic morals, from capros (excreta) + sepsis (putrefaction) + deon (obligation) + -itis (inflammation). Although highly infectious and amenable only to autodidactic treatment, quarantining prevents opportunities for others to develop herd-immunity and insulates the patient from feedback loops required for generating suitable antibodies. Therefore, controlled exposure through social integration seems the optimal treatment-setting for suspected carriers. When pandemic, acute signs accepted as population baseline norms render differential diagnosis impossible prior to acute crises, at which point caregivers are equally at risk and recovery may appear aleatoric.

Woosh.

I think you definitely should have checked for a Babinski reflex.

Otherwise you did good. I probably would have guessed at the pneumonia as a working dx from the get go, mostly because of the skin. Did she have any hx of cough or sputum? Oh, I forgot she was in a NH so yo probably wouldn't know.

Anyhoo, ntg wont hurt, beta agonist may or may not have helped, although it may have been a good idea to try it, and lasix definitely wouldn't help and is not reversible so good call holding off on it.

Several ER docs I have come into contact with recently during my training have mentioned that the differential dx between COPD and CHF is often a very difficult one and that they would not rely on a clinical dx alone. They do the blood work and the chest x-ray before administering anything. So don't sweat it man.

Beta 2 agonist though. Hmmmm....I understand your concern with the cardiac side effects but it may have been worth a go. I just learned a wicked awesome way to nebulize meds while ventilating with a BVM.

CPAP would probably be a good idea actually. However the problem doesn't lie with our BH but rather with our tax base. Our service does not carry this nifty little device unfortunately.

That isn't really a solution. It's actually more of a root of the problem. The current availability and acceptability of abortion is responsible for the societal cheapening of human life that results in people thinking nothing of flushing one down the toilet or leaving it in a dumpster. If medical murder were not accepted by society, then we wouldn't have this slippery slope that allows people to rationalize committing murder themselves.

Oh, you're in big trouble now mister!

Unfortunately there is absolutely no truth to your statement. It would be nice if we could say that one particular thing, and recently occurring thing no less, is to blame for the cheapening of human life. the fact of the matter is that, as I believe you have pointed out previously, that if we go back to fundamentals of life, the weak do not survive. Also, those with weak parents do not survive. ("weak" is not being used here in any judgmental way, only for lack of a better word. "Weak" is used to describe the failure to survive. That's all.)

Murder existed long before abortion was legalized. Abortions occurred long before they were legalized. The difference is that women can now have a fairly good chance of surviving the procedure with reproductive organs intact. Infanticide is hardly a new idea either. In fact I counter your argument by saying that human life is held in much higher esteem in this mode3rn world then it ever was in the past. What do you think happened to malformed or mentally retarded children 200 years ago? Do you think they were actively integrated into society? Were there equal opportunity trash bins? You all seem to forget what the alternative to welfare and social assistance is. Never mind the huge existing inequalities especially in American society but imagine if it was not only possible but common for people to have no income? Can you imagine what having NO income means for your life, your health, your future, you’re offspring? How can you condemn a woman for attempting to kill a parasite that will have a retched life and ruin any chance for her to improve her life….and in the same breath say that this same woman should not have any support by society? It just isn’t logical. Let’s take these people off social assistance and see how the infanticide and unwanted pregnancy rate rises. Oh sorry lady, I know you have no shelter and nothing to eat but why didn’t you take birth control?!! Ridiculous.

Also, men have a sweet escape from this whole issue. In fact it’s a non-issue for them. A young man can be ignorant and irresponsible and uneducated or whatever but he will never have to face the problem of having a parasitic growth ruining his life. In fact he can disappear and forget any responsibility. This woman is just trying to do the same. I am not condoning her actions but rather I am trying to offer some understanding because after reading all these posts that seems to be what is most lacking. This is a societal problem people, your society, and you are your society.

In conclusion…..abortion is not the cause of any of these problems. If I didn’t know you Dust I might be annoyed at your stupidity but since I know you are not a stupid person I believe that you don't even really believe this.

As long as I am digging myself a hole here I figure why stop now? Adoption is something I just don’t get. Why would you want the offspring of someone who cannot care for their offspring? According to me in the vast majority of cases a failure to be able to care for your offspring indicates a failure in life and therefore more then likely a failure in genetics ,biology and environment. Also, how healthy do you think a baby is going to be that has been incubated by someone who doesn’t want it. Why would I quit smoking and drugs and take my folic acid and maternal vitamins to ensure the health of a being that I don’t want and don’t want to raise? The motivation is much less. Anyhoo, I have good genes and functioning reproductive organs and am willing to provide you with offspring for a price. :twisted:

This is why I have such a strong opinion about a person who can just throw their baby away as this girl did. It will continue to happen until the law reaches out and says enough is enough and truly starts punishing them. It should not matter what your background is, nothing makes up for attempting to murder your child. In my opinion, when it comes to a baby or child, there should be no psychological defense. The baby is the victim not the perpetrator. It's time to stop these incidents from happening.

The way the War on Drugs has eliminated illegal drug usage from the U.S.? Perhaps you mean the way the death penalty put a stop to murder?

Excellent point Dwayne. You just saved me a lot of time.

Yay Dwayne! /me waving my flag and recruiting cheerleaders. :hello1:

She didn't say they needed to be punished. She said they need to be more severely punished. Apparently, prison isn't severe enough. Perhaps there is a point to that.

Hahaha! Spoken like a true Texan!

Perhaps there is a point to that but it’s much more likely that there isn’t. How well is your death penalty working as a deterrent Mr. Texas? What form of punishment is more severe then death?

Okay dokay. If you were going to intubate him (which is what I was thinking) what drugs would you give him? Also, is your only rational to intubate because purple = intubate?

We don't carry albuterol and we wouldn't pour it down the tube if we did I am sure. Interesting point...the doc gave this pt mag sulf at the ER.

For me the question about giving Epi sc or not was two fold. According to our protocols only asthmatic pts who are 50 y/o or younger can receive it for SOB non anaphylactic in nature. The rational for this according to me, is that older pts have a higher tendency towards CAD and subsequently more cardiac complications with Epi. Plus this guy was already pretty tachycardic. So the problem here of course is that I don't have a very good history on this guy and I don't know exactly how old he is, but he is in the fifty y/o vicinity.

I think I would have at least attempted to tube this guy. The more I think about it the more sense it would have made. If he pinked up enough they could extubate him at the hospital.

This is another call where the most difficult decision is whether to be aggressive or conservative.

Around here there are a lot of one way streets. The two main roads traveling across town from east to west are both four or five lanes and one way (in opposite directions). According to me, this creates a perfect atmosphere for running red lights for two main reasons; cars are traveling faster, and more importantly there are no cars turning left in the opposing direction when the light turns yellow. Anyhoo, they have red light cameras up every where and they'll get you a hefty 180$ ticket in the mail (so I hear, of course :wink: ). I've got to say, with no data to back me up, that I credit these cameras with reducing in-town fatalities.

Another issue which has recently arisen with these cameras is the ambulance going through a red light. One of our medics was mailed a ticket for not coming to a complete stop at a red light, before proceeding through the intersection. The city (the employer) paid this ticket. From one pot into another I guess.....and we all received an email reminding us to come to a full stop before continuing through an intersection against the light.

I've heard it called "cellitis". I was initially wondering why someone would call an ambulance because they were fat; It's hardly an acute condition. Then it was explained to me. =P~

Hey wait, she still has rights, even if you think after what she did was horrendous.

This is what a cop told me.

The problem with society is when they have kids, it's welfare that gives them money to live on, a roof over their heads and green stamps. So welfare to them is, they never have to work, the more kids you have, the more money welfare will provide for you.

Holy Sh!t

Are you telling me that all this time I could have been living large on welfare and all I had to do was have some offsrping?

And here I am wasting all my time on education and crap like that trying to have a better life. WTF was I thinking?

Seriously though folks. According to me it happens enough that women deliver children and seem to have been oblivious to the fact that they were even pregnant, that we can safely accept this as a reality that will not change. I offer a couple possible explanations; periods are not always regular for all women especially if you are undergoing excessive wt loss or an unhealthy lifestyle which is not unusual for the lower socio-economic classes for whatever reason (that is a whole other topic- but it has been proven that there is a definite correlation). Also, look around you - or in the mirror- North America. We are a bunch of pretty hefty individuals and it really isn't very hard to not notice the distribution of the fat changing form one body area to another. Never mind all the complicated psychological reasons. Regardless of the why, the truth of the matter remains that not all women are aware of being pregnant.

Having accepted the problem we can now move onto finding solutions. I see two feasible solutions. The first, get those damn pharmaceutical companies doing some research on how to produce an oral contraceptive for men. Condoms just aren't filling the niche (no pun intended). And two, make abortion more easily accessible and affordable. The real question brought to mind here is why are these unwanted babies being born?

Uhoh......

I also frequently come across this. As Rid said if you ask a few questions you can usually figure out whether it is an actual allergy or not, and thus whether you can administer ASA.

I actually had a pt who presented almost exactly like this scenario. I bagged her up while my partner prepared to intubate and her HR came right up as well as her BP and spontaneous respiratory rate. I can't remember what happened with this pt or what her final dx was either. Too bad. The only difference with this pt is that she continued to tolerate being intubated even with her improved vital signs. I think we were suspecting a CVA with other respiratory complications.

So, although the answer has already been provided I was thinking one of two things for this pt. First I would try ventilating her, plain and simple. Then I was going to ask about Parkinson’s meds. I have had another pt who had just taken his levodopa and levocarb (I think it was) and who's BP abruptly dropped into his boots. He was also on beta blockers so there was no compensatory HR increase. A fluid bolus did it for this gentleman. No atropine, Dopamine or anything.

It goes to show that there is no teacher like experience.

I am learning that often the toughest call to make is whether to treat aggressively or conservatively. Neither is right in all situations.

Hey I'm there for someone if they want my help. If not that is their choice. I'm not here to judge them...only help them find their way.

The rest, well that's up to them.

This just goes to show that a pretty one is not necessarily a dumb one. :wink:

Humans like to try to destroy themselves. I don't know why this is and I don't see any other animal doing it. Perhaps that is what separates 'man from the beasts'.

I find it a little ironic when the Paramedic sitting on his big fat fast food eating ass is criticizing the pt who smoked for twenty years and now has emphysema, or worse still is debating whether this pt deserves medical care because he “brought the illness on himself”. Or the weekend party animal who verbally degrades their alcoholic pt who has become a frequent flyer because of illness and lifestyle directly related to his/her addiction.

Some really smart guy said once that the first person to throw a rock should be the guy who is perfect...........or something like that.

I am considering............Nah. I don’t think that it has been shown that the scenario was misunderstood. It went awry too early on. No one else has demonstrated any opinion one way or another about what they suspect is happening with this pt.

I don’t think it's so preposterous for someone presented with even the absolute basics of this case to come to a pretty probable conclusion on the pts condition. Basic facts initially presented being that the pt is severely hypoxic, demonstrated by colour and decreased LOC and he has a respiratory hx- most likely late stage COPD- illustrated by the presence of home O2. With this information alone it would be fair for anyone to jump immediately to airway management and ventilatory treatment. Even if the pts primary problem was not respiratory in origin.....no breathy no livey, and so we take care of this first. How can you disagree?

As far as taking care of the basics first goes, I can not assume anything of anyone on this forum. I don't know what the training or skill level of the people who are responding to the post is. It would be inappropriate to assume they are anything more then EMT-b's looking for a little brain teaser. The average level of knowledge on this board is often on the low end of the scale - don’t get me wrong I have nothing but praise for those who seek knowledge- but the fact remains that basic interventions don't go without saying. Since I don't know you this also applies to you. Just because this is a post made in the ALS forum doesn't mean that only ALS trained individuals can and will answer.

How rude of me to say Google when you clearly went straight to Wikipedia. How dare I? Babinski schmaminski. Do whatever assessments you want whether they are valid or not. If "someone who knows more then you do told you to" is enough reason for you then go ahead. I am still not entirely convinced that you aren’t motivated by a need to impress people but I am still giving you the benefit of the doubt. And I am sure what I think is utterly irrelevant to you. But I digress........

Anyways, maybe we can get back to the scenario.

Praise the Lord!

="fiznat"]

Again, assuming this is indeed reactive airway, why cant you administer nebulised meds to a patient who is not intubated? Is this written in your protocol somewhere? You don't have to stop bagging a patient to administer a treatment, either. It is a bit of a funky setup, but a BVM and nebuliser chamber can be attached together in a way so that you bag in a treatment. I have done this before, and it works really well.

Please express your ideas. If you don't think it is reactive airways what do you think the problem is? I believe I have answered all your questions about pt presentation. Do you need more information?

I have never seen what you describe being done and I don't believe that it would be considered kosher by my BH however I am interested none the less. Improvisation is the name of the game.

Fiznat, you are on the right track with the dystonic symptoms BUT, I fail to see what either of these do with the scenario. I would think to argue with the original poster, Mr. hammerpcp, would prove to be an excercise in futility. In his postings he would appear to have little to no respect for anyone other than himself, with all the namecalling and such..

Such eloquent verbage... :roll:

Blah blah blah.

Fiznat, thumbs up for trying to throw in a bit of education into the mix.....Appearantly some are in it more for the argument than for the solution. Not at all worth the effort, but absolutely amusing.

You speak of education? That was the entire goal of the original post. You are completely mistaken about my motives. Fiznat is a big boy I am sure he is capable of defending himself without a cheerleading squad.

Whether to intubate a Pt experiencing an exacerbation of a reactive airway disease is a very real and current debate. One that I was interested in getting the views of my colleagues on. Needless to say, I was immensely disappointed at the response. Not only the weak responses that were received - we all started somewhere and I fault no one for asking questions or suggesting long shots, although I may find it humorous - however, I do have a problem with people trying to misrepresent their own knowledge and trying to make others look less capable under false pretenses.

Another very pertinent debate that may have arose form this scenario is whether or not to administer epinephrine to this pt. Whether the benefits outweigh the risks.

In the prehospital setting, in my service this is a touchy debate because obviously we do not have access to all the medications that they do in the ER. For example, we can not administer MDI medication to a pt who is not intubated, but in order to administer a nebulized bronchodilator one would have to stop bagging this pt. So what do you do?

Also, we do not have the capacity for RSI, so the question is even if you CAN intubate this pt, due to his large size and copious amounts of soft tissue, will topical lidocaine alone be enough to dampen his gag reflex? And then can we sedate him post intubation, or will that create too many other systemic complications i.e. a further drop in BP, etc.

Then there is the concern that intubated COPD pts often end up having a poorer outcome then non-intubated pts so the alternative of BiPap is often a good one but again unfortunately not an option for us prehospitally. BUT can this pt afford to be hypoxic for another five, ten or fifteen minutes while we extricate him and give him nebulization treatments and/or suction the secretions from his airway?

So, as you can see this could be a very interesting, educational and pertinent discussion about topics that we CAN understand, and CAN make a difference about.

As far as respect goes, make no assumptions of MR Hammerpcp. Let me explain SOP to you: In general a base line of respect is forwarded to every individual, call it the benefit of the doubt. But then it is up to the other person to either foster and nurture that respect……being honest and having integrity, not misrepresenting themselves or being hypocritical……or to lose that respect by doing the opposite. You do the same no doubt.

Sigh.

The reason we check for neurological signs in an unconscious patient is to rule out factors that may be contributing to the entire presentation. Ever heard of an overdose? How about respiratory insufficiency secondary to any other pathology? (hint: this happens a lot). To find fault in the fact that I did not treat and assess airway issues before asking about neurological function on an internet posting board is pretty silly. OBVIOUSLY you deal with these things first. This is the ALS forum. Would you like me to walk you through positioning of the airway, inserting basic adjuncts, and ventilating? How about we go over how to plug the oxygen tubing to the D tank? BLS comes before ALS, of course, but get a grip. We assess, then treat.

I am not faulting you for doing a full assessment. I am faulting you for that being your priority when it shouldn’t be. Assessments are done in a certain order of life sustaining priority because if we find a problem during one of our assessments….for example airway……we intervene. We treat immediately and continue the rest of the assessment later if possible. This means that in situations like the one posted, we would assess the pts airway and breathing (as of course you know more then one assessment can often be made at a time hence the importance of ‘the look test’) recognize there is a problem and treat it immediately.

A full neurological exam, or at least a rapid field exam, would be absolutely appropriate in this case. Do we know if this patient is unconscious because he his hypoxic or hypoxic because he is unconscious? Obese patients have big problems maintaining their airways (and diaphragmatic pressures) when they are conscious and able to optimally position themselves, so imagine those issues compounded in someone who is unconscious. You say you could not hear lung sounds. Is this because of his size or because there is a pulmonary issue?

That is the smartest thing I have heard you say in days! So which do you think it is with this pt? With the tools at hand (SpO2 sensor and your senses) how would you proceed with treatment?

How come he couldn't have stroked out and slumped himself into hypoxia? Why not a sugar problem, an overdose, a seizure, trauma, or cardiac? You seem to be ready to load this patient up with bronchodilators and epinephrine, and you haven't even done a complete assessment! Excuse me for my interest in being a little bit more thorough before we start throwing drugs around.

You know this is a brilliant post. I think you may have swayed my opinion of you although I still suspect you of having some misplaced and possibly unmerited arrogance. I did do a thorough assessment on this pt in ‘real life’ and came to the conclusions that I did (I did omit the planter flexion vs. extension assessment ) and treated accordingly. There were many other options in how to manage this pt in retrospect, hence the post. To gather the opinions and ideas of others. Preferably competent others.

To argue that I "don't understand" what plantar reflex means is tantamount to me saying that you might as well not check pupil response, or do a Cincinnati stroke scale because I doubt you could adequately detail the exact pathologies involved there, either. Can you tell me the cellular reactions that give nitro it's vasodilatory effect? Can you explain to anyone in true detail how adenosine causes it's nodal blocking? No, you cant. The reason you perform these tests, and the reason you give these drugs, is because someone who knows more than you told you that you should. You and I are paramedics, not doctors or medical scientists on any level. To say that I am not a good paramedic (or even a paramedic at all??) because my knowledge does not reach to the infinite details of cellular and neurological minituae is absolutely preposterous.

Actually I do have a certain level of understanding of all the assessments that I do and what the findings mean. Understanding at a cellular level especially with pharmaceuticals is not only irrelevant (in a ‘need-to-know’ kind of way) but often impossible since the “exact mechanism of action is not fully understood” more frequently then not. You won’t catch me assessing for heart sounds in a more in depth way then that they are present or not either. This is because the different sounds mean nothing to me. I may hear an abnormality but will that change my treatment? Will I even be able to identify what is causing the abnormality? No. so I don’t check. I don’t do assessments simply because someone told me I should. If I am unable to interpret the results of the assessment, which can be very nuanced (is it a KEN-TUCK-Y or a Ten-nes-see? ) and therefore the assessment has to be repeated anyway by someone who can interpret the findings, what is the point?

I think I am seeing the problem now. Maybe this is a fundamental issue; meaning that your system and training is set up differently then mine at the most basic level. You have the approach of a technician in that ‘if you find such and such symptom you do so and so’. Whereas we are trained more as clinicians in that ‘if you find such and such a sign it could indicate so and so or this and this and therefore you should try that and that to correct the problem’. Clear as mud? Inevitably of course there is over lap between the two approaches, neither is completely pure.

I am giving you the benefit of the doubt now. It is possible that I misinterpreted your doing assessments you don’t fully understand as an attempt to make yourself out to be something that you aren’t; someone more skilled and knowledgeable then you are. And of course the only motivation a person has for doing this is because their penis is small.

In actuality it seems that this is not your situation. That perhaps you do not have a small penis or at least you are not concerned enough about it to try and compensate (are you smiling yet?) for it. But that you are simply doing what “someone who knows more than you told you that you should”.

It seems you would rather argue then talk about this patient anyways, so please feel free.

I hope you realize that this is not the case.

8)