hammerpcp

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........ Praise the Lord! 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.

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. 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. 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? 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. 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”. I hope you realize that this is not the case. 8)

You told me what you found in a wikipedia search. I often find myself waiting with bated breath for someone to regurgitate Wikipedia’s often mis-information to me. Oh wait. I can read for myself. How do you know it’s a valuable finding? You don’t even know what it means! In fact I find the Babinski reflex very interesting. The real problem here is that I don’t want to hear about it from you. This is because you admittedly are doing an assessment – perhaps incorrectly as well?- that you don’t understand, that has no bearing on your treatment or working diagnoses of the pt. I can only presume that you are motivated to do this assessment by the potential little ego stroking you may receive when giving report. When you, or anyone pretends to know more then they do, they look ridiculous and are pretending to be something they are not. Those who need their egos stroked, especially when it is not merited, are frequently insecure about certain personal attributes. By the power of Google thou art now the expert? You are really being ridiculous. You clearly demonstrated in this scenario at what level you are performing and that is poorly at best. For a working paramedic to be focusing on neurological symptoms (that he doesn’t understand… ….but we’ve been over that) on a pt that is in near respiratory failure prior to securing an airway, breathing or any treatment interventions is laughable. And now you play the scholar; The person pointing fingers at others for lacking knowledge in a certain area, when you have just failed at performing even the most basic of life saving interventions. Get off your high horse. Are you even a paramedic? You are in no position to make any judgments about anyone’s creditability at this point. The fact of the matter is that you had no problem with participating in this scenario and thus any slights you make about it now can only be interpreted as you being resentful. In addition your treatment/interventions were poorly prioritized at best, and completely incompetent at worst. On top of that, you are a phony trying to take credit for, and not only that but put others down! For information you don’t even hold yourself!!! 8)

Way to kill the scenario oh Google Master. Let me read what you wrote very carefully.........Hmmmm.......okay I think I get the main point here: YOU DON"T KNOW! So STFU! I am not about to start doing an exam which will ultimately not change my working diagnosis and definitely not my treatment of a pt........I wonder if you are even doing it correctly...Hmmm..... Also I have no need to demonstrate to everyone in the ER when I am giving my report that I have an exceptionally small penis and therefore must make up for it by pretending to know more then I do. Using the pts bipap? Are you serious? And then WTF are we going to do Einstein? Hang out with his super cool winner of a brother, have a few Lakeports and smoke a pack of Dunnhills while the fire boys figure it out? And you are not tubing him because you don’t think it will survive the ride? Ever heard of tape? How good a seal do you think you can get with one person and the BVM on a face that looks like a deformed watermelon? I would be considering other factors in the big tube or not to tube decision....Like, how about is the tube going to make him worse? I don’t know about you but id rather breathe through a funnel then a straw any day. Or how about the fact that dude has a gag reflex? Vomit anyone? Or maybe even that we haven’t tried ANTYTHING yet! Did anyone notice that this guy was PURPLE!!!!!????? And that he was sating at 73%??? And that he had NO AIR ENTRY???? Helloooooo!!!!!!!!!!!????? How about some bronchodilators? How about some epinephrine even? Come on people. Like I said I ain't no brain scientist, but I sure as hell know that this Pt is not hypoxic and damn near dead from a sugar overdose and a nasal cannula at 2lpm. OH the humanity! 8)

Okay.....So number one who cares who said what when.....there are fire monkeys on scene to assist you. Number two, the purple/blue colour to this guy is central cyanosis not purple soda induced..........although thats funny. Number three, FYI beached whales die because they cant breath...but whales breath air so WTF right? They do literally crush themselves to death. Their diaphragm can't descend and there thorax can not expand. Fourthly (if that is a word) it has occurred to me that this post may have been better placed in the scenario section of the forum, and I am frankly disappointed that no one has come out of the woodwork self righteously "screaming" such. Tsk Tsk you guys are losing it. Haha. Some one wrote that "you will eventually have to tube this guy". And I though :AHA! there in lies the real question. Now back to our regularly scheduled program. OKay so you've sat the Pt up with the assistance of two of the firemonkeys and propped him up with clothes/pillows lying around the room and you are bagging him via BVM. Within the first minute his colour improves quite dramatically although he still quite a ways from human looking. He has some saliva coming out of his mouth. He has also become slightly more rousable. When you manually open his eyes he seems to have a purposeful gaze and he makes some incomprehensible sounds when you provide loud verbal stimuli in is ear. At this point you don't think your pt will take an OPA but your partner is on it and is inserting a NPA. Result: R nostril you meet resistance. L nostril goes in fairly smoothly until the end when your pt has a gag reflex and a minor epistaxis. (oops) No more History for you, sorry. But bro knows there are no allergies. As requested: Full set of vital signs: HR 120 sinus tachycardia. SpO2 88% with BVM and modified jaw thrust. RR spontaneous @ 30 (bagged slightly slower). BP 110/80 -Lung sounds: You can't hear shit. -Blood sugar: 7.8 mmol/l (slightly above average values, but probably normal for this guy) -ETCO2 would be nice to really evaluate that breathing/perfusion/etc: We don't have the capacity to measure this but I can tell you he is hypercarbic through the roof. -Neuro checks (pupils, reactivity to painful stimuli, babinski, etc):pupils are reactive and equal, he seems to be moving all extremities.....I'm not giong to do a babinski reflex check until someone can explain to me what extrapyramidal really means. Sorry. -Physical exam. Is the purple color cyanosis: yes. Purple is cyanosis. Okay so the fire monkeys are feeling extremely manly after the bbq they had for breakfast and opt out of calling for more assistance. The six of you should be able to do it. You already have a fat mat/tarp (which rips BTW :shock: but is still usable). Now, my question for you all is what is your next treatment decision? You know you are going to have to stop bagging this pt at effectually for up to five minutes as you extricated him form the residence. Are you thinking of any pharmacotherapies? Intubation? Someone mentioned something that needs addressing because I can't stand misinformation. You can't overdose on sugar. If you aren't physiologically normal then you can become hyperglycemic but thats different. Maybe it's just semantics but I had to say something.

Hmmm....interesting suggestions. First I am against cell phones, [rant/on] more specifically I am against astronomical bills and mega corporations that think they can treat their customers however they want [rant/off] , so i don't have one....also there is that sticky little pt confidentiality issue. But you're in luck, four well rested and fed fire boys are right behind you as well as your ever-prepared partner with the cardiac monitor/defib and O2 bag. Brother is MIA. He seems to have gone out for a pack of smokes. He does tell you that he found the Pt in this condition approx one-two hours ago. The brother could not rouse pt so he gave him some more time....perhaps to sleep it off? I dunno. When the brother could not wake him still he called the family Dr who called 911. Head tilt chin lift wont help this dude much on its own. He is purple. What about sitting him up? Perhaps a little beached whale syndrome? I'm no rocket surgeon but there is no chance that the NC caused hypoxia. Okay so no mouth to mouth because your partner has saved the day with your equipment bag. BVM it is! Negative for grape soda cans.......not sure about the relevance of that but what the hey. so you get your little three leads on the guy...who is soaking wet....and your pulse oximetry......you have a sinus tachycardia about 120 and an SpO2 of 73%. You also scrounge up some meds: blue puffer, orange puffer, grey puffer type dealy and some pills for reactive airways (non steroidal), also some lasix. But that's it. The colour coded meds is just a little test for no particular reason. I will name them if you need.

Called highest priority to a residence....call made by a third party caller- apparently a dr's office- for a possible seizure. So you arrive scene and follow a guy into a bedroom at the back of the residence where the pt supposedly is. you left everything in the truck because you're cool like that. You come around the final corner to see........A big fat guy.....i mean BIG..I'd put him at just under five hundred......approx 50 y/o male, in bed naked (why god why?), is is sporting a lovely shade of purple/blue from head to toe, is breathing spontaneously at approx 26 bpm shallow, he has on a nasal cannula, he is not rousable to loud verbal or painful stimulus.....his brother tells you (after you've sent one of the fire guys to track him down) that this pt has CPOD and thats all he knows about hx. You're on!

I thought you would be accustomed to feeling inadequate by now. Oh I am. I live in constant fear. :shock:

Beautiful.

You give lorazepam and now he's apneic. The good news is the sz activity has stopped. What now? (Is this the worlds most long and drawn out scenario or what?)

Sorry folks....I didn't intend to abandon this thread but I got busy. Anyhoo........I did not take spinal precautions. That seems a little ridiculous actually but whatever. The pt continued this sz activity. He actually deteriorated en route, losing his gag reflex and saliva began coming out of his mouth. My question to you all is would you intubate? You wouldn't need RSI at this point, but if you were going to administer pharmacologic therapy what and why and how much would you use?

Okay guys and gals.....anticholinergics for reactive A/W disease? Like what?

Wendy, Since you have freakishly large frontal lobes could you please explain this (above) to me/us? What exactly is a "full orientation questionnaire"?

I'm back. So apparently this girl has a canine bleeding disorder. That's your first problem right there. She's the wrong species! Quick someone call a mediVet STAT! Did the RN administer anything to this pt? Dextrose for example? Oxygen or assisted ventilations?

Clearly for the greater good you need to dip your pinky in and sample this mysterious substance. WTF is von wilderbeast disease? Google here I come.

Hmmm......If only life were that simple and we could just hand off all our pt's to someone else. For the sake of my education (and possibly yours), does any one else have any treatment suggestions? Assuming we have more then an oral airway, glucagon and a BVM at our disposal. 8)

1mg glucagon administered subcutaneously with no change. I would call this a complex partial sz. Pediatric pts don’t tend to have grand mal aka generalized motor type sz. As previously stated pt has no meds, no hx, no allergies. Who wants to get moving with this kid? Good idea. Enroute pt's tremens begin to get a bit larger- still primarily in left arm. Pts Sat drops to 92 and he seems to have a decreased respiratory effort and rate. Side note: My vehicular laboratory is currently not working. Epilepsy foundation

Great questions! That's exactly what I asked. The answers were that the pt slumped to the ground. The teacher guided him so there was no trauma. There was no tonic or clonic type activity but he did continue to have tremors primarily in the left arm. No gurgling, no vomit, no tongue biting, no verbal utterances. Unknown if any alterations in respiration. Another great Question! I asked that one too As it turns out the child had remained lying on the floor until the firemonkeys came in and promptly stood him up. The pt has been in his current condition for approximately 20 minutes so far with no changes. Crazy, to quote hit the quote button at the top of the boxy thing (very technical I know). Or you can type in [q u o t e =hammerpcp] text to be quoted [/q u o t e] Without all the spaces though.

Okay, so you slap the sh!t out of him and then the teachers get mad about having to clean the poo up. No response to any stimuli. You snap your fingers in front of his eyes and his gaze does not change. He does not respond to painful stimuli applied to any extremity or shoulder. Doesn't follow any commands. He is able to stand and walk unassisted- no paralysis of the lower limbs. Both arms are moving occasionally with some minor tremors in the left. Pt has been incontinent of urine. Every one denies recent trauma and there are no visible wounds/contusions etc. Stressors (I am assuming you are asking about psychological stressors) are unknown but it doesn't seem likely. Heart rate is around 130 bpm and is sinus on the monitor. Sats are 98-100% (Fire has applied O2-they get a little credit even though I am sure there was no critical thinking involved in this decision). Strong palpable pulses distally in all extremities (your BP cuff is too small for his leg and too large for his arm.) His colour isn't bad and there is no diaphoresis. Pt is breathing at approx 20-22 breaths per minute and they seem adequate. CBG is "Lo" which means it is below 1.1 mmol/L. Pupils are 6 and non reactive according to your partner who may or may not be an idiot (it's your first shift together). So? EDIT: to include profanity.

Yes, this child is the patient. Good idea to take over from the firemonkeys. They have been coddling and talking to the pt. When you take over you notice that the child is still looking to the left and is not responding to you or even acknowledging your presence. The teachers say that this child was reading in another room in the library when one of them tried to talk to him and he would not respond. The teacher then led the child into the adjoining room- he walked on his own but needed to be guided in the direction the teacher wanted him to go. He was still verbally unresponsive and did not seem to be making movements with any particular purpose. For example, he would walk a few steps in one direction as if with intent, but would then stand there "looking off into space". After approximately ten minutes with this teacher, the boy apparently took several steps and then collapsed to the ground. At this point 911 was activated. The boy's eyes remained open while on the floor and he still appeared to be looking off to the left. The pt has no medical history, no allergies and nothing like this has ever happened before according to staff and parents who were notified by phone. Your next move?

Called to a school code four (lights and sirens) tiered response with fire right ahead of you. You get the call as a five y/o male SOB. Arrive scene-elementary school, pt is in the library with several teachers present. You see a child in no obvious distress, standing, fire department surrounding and talking to him, he appears to be looking away form you. Let's start form the basics. What's your first move?

Hmmmmm..............vewy intewesting. Apparently MagSulf increases the production of the vasodilator prostacyclin......Its antiarrhythmic effects may be related to its role in maintaining intercellular potassium.............and it may also act as a natural calcium channel blocker........ Who knew. Thanks for the insight(s) all. Perhaps it is not more widely used in COPD exacerbation because of the lack of scientific evidence?

ERDoc, The person who told me about this, recounted that the Dr (one who came up from Louisiana or some such place) said that they could administer as much mag as they wanted because there was little chance of adverse effects. Mind you this info is third hand, but could you tell us more about mag toxicity? What are the risks? What kind of dosages are therapeutic and what are harmful? Apparently none of the doc's on in the ER that night had ever heard of such a bizarre treatment. I am dumfounded. And AK, No this is not Hammerpcp, this is just a pleasant dream. :wink: