hammerpcp

Whatever dude, I'm not here to prove anything to you. You said you didn't know what it was so I told you as much as I know.

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.

I am a paramedic, not a neurologist, and while I cannot trace the pathology of plantar reflex for you to it's minituae, I can tell you without a doubt that it is a valuable finding,

How do you know it’s a valuable finding? You don’t even know what it means!

and an easy test to do, for any potentially neuro-compromised patient. If you don't feel it is necessary, and would rather not read about it, then honestly I really could give a shit.

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.

Every medic here, though, should know what a freaking extrapyramidal (AKA dystonic) reaction is. The fact that you confused this (with two names specifically excluding one from another!) doesn't bode well at all.

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.

Perhaps if you presented your "case study" (if that is even what this is) in a more organized and professional manner, you would get a few more serious supplies. When you openly mock a patient for his weight, then admit that you didn't even bring in any of your gear to the call, your credibility tends to slide down a few notches. Using childish name calling and references to penis size in response to a legitimate reply to your thread doesn't help either. Get over yourself.

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 hate it when he does this. It makes me feel so damn inadequate. :?

I thought you would be accustomed to feeling inadequate by now.

I just saw an interesting commercial on CNN. A Johnson & Johnson sponsored commercial promoting this website showed three different nurses portrayed in action. One of them was bagging an intubated patient in the back of a rolling ambulance. Another was kneeling beside a motorcycle accident victim on a highway. Only one of the three was in a hospital. I have to admit that I am far removed from nursing politics these days, so I don't know if there is some current initiative to push nursing into a bigger EMS role. Quite probably, the commercial was just sensationalising nursing to appeal to those people who would never consider the field because it is stereotyped as boring by most. Regardless, it is interesting.

Be afraid!

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?

I really want to know the AAOx? of our patients and how they're tracking per a full orientation questionnaire...

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

>Can we get a more specific description of this "collapse"? Was it a fall direct to the ground, with no hands put out for protection, how did the child drop, was it stiff or was he limp and slumped to the ground? Was there any motion during that time, any tonic/clonic activity, any coordinated or uncoordinated muscle movement? Was there any alteration in respiration? Any report of gurgling noises or any utterance at all from the child? Was there any deviation of eyes or did they remain fixed to the left the entire time.

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.

I also want to know- you said the child is standing but still unresponsive? Did he get up right after he fell? Get some info about this transition from on the floor to back standing up. Did he just get up and then was altered again, or was he out of it the whole time? Hase he been responsive at all?

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.

Slap the sh!t out of him and tell him, "Quick faking it, get back to class slacker!"

I have a few questions, but after that I will stay out of it. Hopefully in my abscence someone else will get it. Does he respond to threatening stimuli from either side? Does he follow an commands? Any obvious paralysis or lack of movement in any area? Is there any loss of bowel or bladder control? Do the parents know of any recent hea trauma? Any recent significant streesors in the boys life?

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?

I use it quite often for more severe asthma and COPD cases. I don't think it is used as much as it should for fear of Mag toxicity. Great little drug that works by smooth muscle relaxation, but you need to watch your pt for toxicity,

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:

Magnesium for asthma exacerbation? Has anyone ever heard of and/or witnesses this treatment? I hear it's damn near miraculous in its effectiveness. So my question is why isn’t this standard treatment? If you know anything about this please share.

:laughing6:

<sighs> Ya, I know, the problem with being perfect is that everyone gets sooooo jealous!

I guess I'll just have to live with it. <another sigh> #-o

Actually that wasn't directed at you, it was meant for Akroez.

But with a mug like yours I'd say you're pretty damn close to perfection yourself.

Shut up, you're perfect.