Doczilla

"In a box under your desk, you will find a razor blade, needle, thread, mirror, and several pieces of gauze. Remove your own appendix. You have 30 minutes. Do not suture until your work has been inspected." 'zilla

Novisen- This last statement of yours may be construed as a challenge to start an argument, and not in a nice way. I suspect that it is simply a matter of things not translating quite right from your language to ours, and that you did not appear to be rude. If you did, then I am more than happy to accommodate you. 'zilla

Propylene glycol is a very common diluent for many injection medications. It is used in antifreeze, but the more "environmentally friendly, non-toxic" kind (Sierra is one brand). In really large quantities it can be dangerous, but not in the quantities typically encountered with injection meds. Propylene glycol is much safer than ethylene glycol (the common ingredient in most commercial antifreeze), which can cause renal failure, acidosis, and death in pretty small quantities. Etomidate is a prescription drug but not a controlled substance, mostly because people haven't seen fit or found a way to abuse it. I've drawn and pushed a whole lot of etomidate, and I would not agree with your supervisor's statement that it is more viscous than D50. Onset of action of etomidate is 30-60 seconds, and duration is approximately 10-15 min. This is important to remember if you push etomidate and a long-acting paralytic such as vecuronium or rocuronium; the patient may wake up and return to full consciousness before the paralytic wears off. I agree completely with giving a benzo (in large doses) to a patient after giving etomidate and the airway is secure. 'zilla

Anthony's situation brings up another good point- any interference by the patient in their own care, interference by family members, threats to sue or other statements of dissatisfaction should be documented in the medical record. Be as specific as possible; quoting the patient as saying, "paramedics are sadists that like to hurt people" is better than saying "the patient makes irrational statements about prehospital personnel" (of course, if talking about Dustdevil, this isn't that irrational). Rather than saying "pt is uncooperative", cite the uncooperative behavior (pt. refuses to hold still for BP readings, pt refuses to answer medical questions and instead screams obscenities at me, pt somnolent and will not follow commands). If a patient clearly wants a certain treatment that you feel is not indicated or you are unable to provide, document this as well. 'zilla

A patient has the right to view medical documentation as it pertains to them at any time so long as the document is complete and signed (alluding to Rid's preference that it be QA reviewed. The signature implies that you have reviewed it and it is correct to the best of your knowledge.). You can make them go through the rigamarole of requesting it through the agency or medical records department if you like, or tell them they need a court order (which isn't true). Making them go through this, however, makes it look like you have something to hide. If there has been a bad outcome, this is only worse for everyone. It's much better for everyone if you just let them see it, so long as they would have the right to the information, (i.e., the patient themselves, or the POA or next of kin if the patient is not competent). As Rid said, it's a good idea to have them sign a release of information form. 1) They should never be left alone with the documentation. If they view it, it should be in the presence of an employee of the agency, preferrably a medical provider who can explain things they don't understand and answer any questions they may have. Because we frequently write in medical shorthand, it will be necessary to translate some abbreviations. (na, ma'am, that's Shortness Of Breath...) 2) Any request by the patient (or family, as appropriate) to view the medical record should also be documented with date, time, and who was present. 3) The chart is the property of the healthcare organization (though the patient or appropriate representative may view it any time), and the patient therefore cannot alter it. As someone else stated, they may dispute the documentation, and this may be noted in the chart. 4) If they want a copy to take with them, they should then go through the agency to obtain one. This entails signing a release of information form that is kept on file. 5) A court order is only necessary to release the information to someone who would not otherwise be entitled to it, i.e., a family member that is not the healthcare POA or generally accepted next of kin (in the case of an incompetent patient). 'zilla

As a learning point here, take note of differing BPs in each arm. This can sometimes be seen in the setting of dissecting thoracic aneurism. I'm not saying that's what's going on here, it just brought this little pearl to mind. 'zilla

Having worked with Kinley, if he says it's positive, then I'm calling the cath lab. That said, most providers in our area do not have his level of skill. If I pull the trigger prematurely on activating the cath lab and the cardiologist does not agree with the findings, this may adversely impact our ability to do cardiac alerts in the future. The cardiac alert system works because the cardiologists have faith in the ER docs, and when we say it's the real deal, they move their butts. When a medic calls it in and I make that phone call to activate prior to arrival in the ED, I am showing a certain amount of faith in the medic as well, and sticking my neck out if the medic is wrong. I don't mind doing this for STEMI (and I've been burned several times already), but feel far less comfortable doing it for interpretation by field providers with criteria that are not completely reliable and on EKGs that they are not that practiced reading. 'zilla

Not really. First off, knowing what Sgarbossa's criteria are is one thing, correctly identifying them quite another. As AZCEP and Rid pointed out, the rule is also not that reliable. I would likely feel some amount of disbelief if a medic wanted to activate the cath lab on that alone. I would not make that call on the basis of a radio report from a medic unless it's someone that I have worked closely with and trust implicitly, and even then, I'd probably hold off until I could see the EKG myself. Cardiology would be unimpressed as well. Until we can show a previous EKG and definite change in the current EKG over baseline or presence of positive cardiac markers in the blood, activation of the cath lab would depend quite a bit on their schedule, time of day, etc. The bottom line is that reliable identification of acute MI on EKG in the presence of LBBB almost always requires comparison with previous EKG. 'zilla

I think this nurse should mind her own business. Until she learns to read an x-ray or give medications independent of direct verbal order, she can take her (incorrect, by the way) Monday-morning-quarterbacking and shove it someplace that can't be reached by a tube. The patient had bronchospasm as evidenced by wheezes. This is caused by an inflammatory process, whether by asthma, COPD, RAD, pneumonia, or fluid overload. A single dose of solu-medrol in this patient who is critically ill will not do any appreciable harm, or at least the risks are far outweighed by the potential benefits to this imminently deteriorating state. This nurse has quite a bit of gall to write you up and question your field treatment of CHF, particularly when the patient didn't have CHF. Staffing must be pretty good at that hospital if she's got time to jump your s&it AND write you up with your supervisor. Punt this to the medical director. He or your supervisor should get into contact with the hospital's EMS coordinator on this. 'zilla

The typical prehospital patient: obese chain-smoking hypertensive type II diabetic vasculopath with CHF. Nobody around here can seem to have any less than 4 of these concurrently. COPD and CHF are separate entities that tend to run in the same circles for several reasons. The biggest reason is because of the same risk factor: smoking. Our hard core COPD patients tend to be dedicated (or until their most recent MI) smokers, which increases the risks of vascular disease, MI, and hypertension, all of which lead to CHF. COPD can lead to pumonary hypertension and right-sided heart failure. This is more likely to result in atrial arrhythmia (a-fib) than pulmonary edema. It is also true that the most common cause of right sided heart failure is left sided heart failure, the latter of which would cause the fluid overload in the lungs. To complicate things even further, fluid overload and left sided heart failure may cause bronchospasm, sometimes referred to as "cardiac asthma". This clouds the clinical picture significantly if you have a patient with a history of cardiovascular disease who has never smoked and is now wheezing. With regard to nebulizing lasix for dyspnea, it's not that well studied or understood. It's far from standard practice on this side of the pond. For terminal cancer patients with dyspnea or neonates with bronchopulmonary dysplasia, this might be worth trying (though evidence here is still pretty thin), but I have yet to see any studies of decent quality demonstrating its benefit in garden-variety CHF or COPD. I'll call this one voodoo until some better evidence comes along. 'zilla

No, but she may have had a blood transfusion before 1985 when we started testing for HIV. Hopefully this would have worked itself out one way or another by now, but there are such things as asymptomatic carriers. She's low risk but not no-risk. This is why incidents like this need to be handled in an ER, not in a worker's comp clinic. You need good advice, and you've had all that you can get at this point. Interrogating the patient's family will not help your decision-making process here. Take your doc's advice and take the meds or don't, but don't fiddle fart around waiting to make up your mind. Make a flippin' decision. Chances of seroconverting HIV from a positive carrier after a bloody hollow-core needlestick: 1/300 Chances of seroconverting Hep C from a positive carrier after a bloody hollow-core needlestick: 1/3. And there's no pharmacological prophylaxis available. Double gloving does actually reduce your risk of transmission from needlesticks. And I agree that running a tube of blood over to a hospital for testing with L&S is stupid. How much time is saved? 5 minutes? 'zilla

Just to correct you here, the antiviral cocktail must be started ASAP after an exposure. Within an hour or two is best. If the rapid (1 hour) HIV test isn't available, then it usually takes 4-7 days for the HIV test to be completed, and it would behove the exposed employee to take the cocktail until the test comes back. 'zilla

In this exposure, it's risk vs. benefit. This is exactly why rapid HIV tests were invented. You can find out within an hour if the pt. is HIV+, then take the cocktail if indicated. The drugs are not "risk free", and yeah, they'll make you feel like crap. That should not discourage anyone from taking them when indicated. Taking them for one month sucks, taking them for a lifetime sucks more. I'm not going to say whether or not you should take them. Another doc- YOUR doc- says you should. You can always stop taking them once the test comes back. I agree with what Ruff said. Your company should (hopefully) have a policy where you can check into the ER at the receiving facility and testing of the patient can be done. Next time, do that. There is a house officer there 24/7 that knows how to handle this sort of thing immediately. Here in Ohio, a patient cannot refuse testing after an exposure of a healthcare worker to the pt's blood. 'zilla

It sounds like you did fine with this patient. I don't see any big misses here. The use of CPAP in mixed cause or undifferentiated acute respiratory distress has shown mixed results, but hasn't shown harm. I don't see any problem with trying it in this patient. The lasix question may not have been a loaded one. In treatment of respiratory failure, even with wheezes, some providers will throw lasix at just about anything. They may have just been checking. You were right not to give it. The steroids were a good idea, even if it does turn out to be pneumonia. The most immediate problem is bronchospasm, which will be partly alleviated by the solu-medrol. For pneumonia in a COPD patient, steroids will frequently be needed to attenuate the inflammatory response causing the wheezing. For this COPD patient, only a chest xray will tell you if it really is pneumonia. If she has a fever, that strengthens the diagnosis. The sputum is not necessarily telling by itself; COPD patients hypersecrete mucus. This case illustrates the complexity of a patient that seems relatively straightforward on first impression. Field diagnosis in respiratory distress is frequently inaccurate (as is ED diagnosis before xrays and bloodwork), and it's never a bad thing to question your initial impression of the patient. 'zilla

I'm advocating the adenosine for diagnostic purposes. Adenosine is not a rate control medication either. It is useful for 2 things: terminating a re-entry tachycardia, and assisting in diagnosis of an undifferentiated tachycardia, the latter of which this patient has. 'zilla

I'm going to jump into the mix here. I don't think you were wrong to give the adenosine. Given our hindsight, yes it looks like sepsis, and a lot of the evidence is pointing that way. Your gut feeling on the heart rate is that it was too high for the clinical situation. I don't see anything wrong with giving the adenosine here to help diagnose the rhythm. I have done this on several occasions to see the underlying atrial activity to confirm my rhythm interpretation of a deliriously high heart rate. Let's keep in mind that our ability to diagnose rhythms at extraordinarily high heart rates in not great. It looks like sinus tach, but at that rate could very well be atrial flutter with rapid conduction. While giving the adenosine is not without risk, it comes with very small risk, smaller than that posed by missing a malignant arrhythmia that is putting the patient in shock and leading to cardiac failure. If you give the adenosine and find that it's sinus tach, then you can go from there, and you have strengthened your diagnosis and may proceed to treat the sepsis and presumed hypovolemia with confidence. If you missed a primary arrhythmia as a presenting problem, you would start dumping in fluid and would rapidly push him into CHF. 'zilla

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Even I know better than to piss off the nurses. 'zilla

Or it works only at really strange hours. And despite letting her watch Grey's Anatomy once or twice, I STILL can't get Wifezilla to join me in the call room for "rounds". 'zilla

Good point. How short-sighted of me. 'zilla

Holy sheep s#it, are we starting this AGAIN?!?! Pyro, so help me I will make it my sole mission to put lidocaine in your Copenhagen if you start this up here... Goes for you too, Ruff. 'zilla

And he can't contain himself when someone asks a question about the utility of tactical EMS training. Gotta beat down the mall ninjas. 'zilla

More recently he walks on sand. And rocks. He cannot go unnoticed in an EMS forum. 'zilla

ER docs don't retire. Their skills become such that they can treat people from home using only The Force. We WOULD treat them all and keep them from darkening the doorway of the ER, but we've got some payback to give to our coworkers. So we sit at home and serve as medical directors for EMS squads. And dream up ways to change the protocols every year. 'zilla still HMFIC

WHAT?! How did I miss this ruckus?! 'zilla, MD, HMFIC