CytochromeP450

Some excellent ideas by all posting here. I was certainly stumped when I saw her. My primary thought was that it was a vagal event, but that would make more sense if she had been pushing hard, but the stool was loose and all symptoms seemed to start together more or less. I also thought it might be some sort of gnarly arrhythmia that was self limiting. I mentioned the case to an old doctor that frequents these parts and he said it sounded a lot like Dumping Syndrome. I had never heard of it before but after looking into it, it sounds like the symptoms are spot on. The patient didn't mention previous gastric surgery and she had no scars on her abdomen, but I imagine there is a possibility that the problem could have an idiopathic origin. This case is quite the reach for any prehospital provider to pick up on, but interesting and good to know regardless.

DJ - the air temperature was 76 and sunny, she was sitting in the car prior to onset so I think heat exhaustion was unlikely. The reoccuring nature with sudden resolution makes me shy away from an infectious process but I wouldn't rule it out. Arctickat - I wish I could say there was something as exciting as THIS in the toilet, but it was really just loose, brown stool. No blood. DFIB - She is definitely hypoperfused...I just couldn't figure out why. She couldn't give me the specifics of her antihypertensive meds, but she said the first time she experienced an episode like this predated the medications so I figured those weren't the cause. Shes never had a copro antigen test. No mucus in the feces. Brown and loose. Smelled bad...like poop...but nothing unnatural. Her oral intake wasn't anything out of the ordinary, she had some freshly made salsa with veggies from the garden but no one else who ate it was ill. She was normothermic with good turgor. She could stand to take orthostatics, but honestly I don't know why you would -- she is already hypotensive when sitting so its not orthostatic hypotension

CH - I agree. Religion is great if mixed with other areas of understanding such as philosophy and science. An individual should use it to guide their own personal ethics, but we should not be in a theocratic society. In fact, all the more conserative yet educated Chritians I know would aggree. They don't think law should be based on religion. They would argue very astutely from their end that the forced or cajoled Christian does not the good Christian make. DFIB - I think you and I are much on the same wavelength in terms of the fundemental message of Christianity. I will say you are much better versed than I would ever pretend to be. I admittedly coppied that quote blindly. The class was great. It was actually taught by professor who was also in the clergy. It was not at all like, "This is what the Church believes and you must beleive it too." Very rational discussion of the ethics behind it. In fact, my entire college was like that. Logic and reason where the primary focus, and religion was used to compliment it. I am not deeply religious, but I honestly beleive my education would not have been as complete without the understanding of a concept of spirituality beyond the constrains of space and time that my school offered. I feel much more rounded because of it.

It is not where you work that makes you a good or bad provider -- it is how you handle yourself. I worked for a private transfer service as a summer job when I was just out of high school. IT WAS A FANTASTIC EXPERIENCE. I learned stuff there that I could never dream of having the opportunity to learn as a 911 medic. Yes, the patients are usually not very sick when you are doing a BLS transfer gig, but there are opportunities to learn literally EVERYWHERE. Things I learned: How to talk to patients (be curtious, value the small talk, take care of the littel things to make them ore comfortable), How to move patients (a bed sheet can be your best friend), I got exposed to TONS of healthcare environments (Not just the ER. This is possibly the single biggest downfall of EMS. So much goes on that many 911 providers are entirely ignorant of. How many are familiar with dialysis? With rehab? These things are important and have their own challanges) I got to read progress and discharge notes from doctors. I got to read med lists (look up every medication you come across...this will do more for you as a provider than you can possibly imagine) I got to read detailed reports on medical problems, cath lab reports, surgery notes, lab values, you name it. The list goes on and on. Transfer is much different than 911. I am a lot better 911 medic because I worked transfer, and if I were to go back I would be a lot better there because I worked 911. It is all what you make of it. If you treat it like a taxi service, it will be a taxi service. If you treat it like the best opportunity to learn, it will be just that. These guys you are working with have no idea what they are missing, but the very fact that they are giving you a hard time about it shows that they are not the type to suck the marrow out of every opportunity to better themselves as a provider.

Bowel sounds are present and of normal frequency and character. Blood pressure is equal on both arms 12 lead shows a sinus rhythm. PRI is 174ms. QRS duration is 76ms. Normal axis. No ST changes. I'll see if I can upload it as an attachment, but it is really quite unremarkable.

Here is an interesting call that I hope you all will find intellectually tantilizing Dispatched to a library for a 60 year old female feeling dizzy. General Impression: You arrived to find the patient sitting on the toilet. She is extremely pale and profoundly diaphoretic. She is responding appropriately when you ask her questions but she is very lethargic. You take a quick pulse and it is 80, reasonably strong and regular. Breathing is non-labored. History of Present Illness: You start talking to the patient and get a story that goes like this -- she was riding in the car when she experienced a sudden, intense need to deficate. She pulls into the library to use the restroom when she sits down and immediately passes copious amounts of watery diarrhea. She reports that around this time she also began feeling a crampy pain in her abdomen, very sweaty, onset of a headache with blurred vision and like evertyhign was going white. She states that her arms and her legs feel a little numb and weak. Mild shortness of breath, no chest pain. Exam: Your physical exam looks like this: General - 60 year old caucasian female, slightly overweight but otherwise normal habitus and grooming. Skin is extremely pale and profoundly diaphoretic. She only opens her eyes to verbal stimuli, lethargic, but oriented in all respects. Head - No signs of trauma, PERL, moist mucus membranes, external nose and ears are normal. Neck - Supple, no JVD, her trachea is midline. Chest - again atraumatic, breath sounds are clear to auscultation in all fields with no adventitial sounds. Abd - diffusly tender, no rebound tenderness, no pulsations/masses/distention/ascites Extremities - + distal circulation with 4+ muscle strength. Neuro - no focal neurologic deficits Vital Signs - BP 82/50, HR 76 and regular, RR 16 unlabored SpO2 93% room air EKG - shows sinus rhythm at a rate of 76 with no ectopy or ST changes Blood Glucose - 123mg/dL History: History of HTN for which she takes a blood pressure medication and a diuretic; she cannot recall the name of either. When asked about a history of these episodes she reports that she has had aproximately 10 over the past few years and they are always associated with a sudden need to deficate and the simultaneous onset of these symptoms. They ususally resolve spontaneously without intervention but this one is significantly worse and has lasted longer than the others. She has never been evaluated for these before. What do you think?

Kiwi, I went on the interwebs to try to find some overly technical definition of a proton to construct a humerously pedantic response. I instinctually clicked the wikipedia entry, and by the time I hit the "description" section my head was spinning...much like the 1/2 integer spin of fermions (hey my snarky joke has been found at last!) but the thought of a simple idea becoming profoundly baffling reminded me of this documentary on time I one saw. It will totally scramble your brain.

Who providers your medical director?

Dwayne, you are starting to tear apart the straw man I had so carefully constructed to defend my claim! So you are saying that based on the equation... Blood pressure = Heart Rate x Stroke Volume x Systemic Vasclar Resistance ...that she is currently in a state of compensated shock, and that her blood pressue has not yet fallen because her heart rate increase had increased her cardiac output. This makes me wonder: If a 50% decrease in SVR is matched by a 50% increase in heart rate, does blood pressue remain the same? Can you make the equation mathematically accurate by adding constants in front of each variable? Or is this only useful in demonstrating concept.

Thank you all for your responses and encouragement. Hoenstly, I loved my education but there are times when I wonder how much good it has done me. I definitely have a better understanding of many things because of it, but I frequently find myself frustrated when it comes to the opportunities, or lack thereof, that it provides. When I look at career options, I either need to go on to more schooling to make it bare fruit, or I find myself lacking the technical certifications for a lateral carrer change -- despite having the foundation and clinical exposure to be very effective at it. I remember someone posting once that, if everyone with potential went on to pursue greener pastures, prehospital care would never grow up from its technican, rather than clinician, oriented mindset. I frequently find myself straddling that fence between the two hypothetical fields. My heart really is in EMS and it is this community that keeps me going. Thank you all.

Okay I am going to do my best to make this coherent, but it is late and I am trying to condense an entire semesters worth of study into a manageable post. So I went to a small, Catholic, liberal-arts college. I am not Catholic, nor was the majority of the student body, but it offered some very valuable educational opportunities. One of the courses I took was called "Christian Healthcare Ethics". We discussed a lot of issues, such as abortion, HIV and contraception use, reproductive sciences and of course Physician assisted suicide (PAS). In terms of euthanasia, there are two ideals that seem to be put at odds with each other -- compassion and sanctity of human life. The Christian perspective puts heavy weight into the sanctity of human life: we are created in God's image thus we must respect ourselves and one another. There are references that we are not the masters of our own lives, but merely stewards of the life given to us by God. But the idea that human life is to be held in higher regard than all other things is something that we seemed to decide with little cause. In fact, the action of Jesus on the cross directly contradict the idea that human life is most important. It was the sacrifice of this sanctity that gave it the significance it has. This is reiterated by early Christian martyrs in choosing to give up their lives rather than using any means possible simply to continue their existence. If we are to hold true that "being alive" is most importance, these actions become unethical. Instead they suggest that there are times when it is appropriate to relinquish your life. The next piece to consider is the morality of the actions of a physician in providing this service. The Bible is pretty clear about murder. You shall not murder is one of the 10 commandments, plain and simple, and there are countless other references. However, I think we need to be more specific about motive. All these references are made in regard to a situation of violence. They contain phrases like "spilling blood upon the ground" and saying that assault on a man is an assault on God. But we are not talking about violence and retribution here. We are talking about an act of compassion, which could very well be argued is the TRUE ideal above all other ideals. Jesus says "love your neighbor as you love yourself". If the cessation of suffering would be the most loving thing someone could provide you with, are we not living the teachings of Christ when we provide euthanasia? In trying to brush up a little on the details of what I remember, I actually found a passage in the Bible that directly supports euthanasia... "Then he begged me, ‘Come over here and put me out of my misery, for I am in terrible pain and want to die.’ “So I killed him,” the Amalekite told David, “for I knew he couldn’t live." Samuel 1:9-10 Basically, what I am trying to get at is that if you take one single line out of context you can come up with an argument for or against just about anything. What we really need to do is look at the work as a whole, and see what the core ethics the book is trying to instill -- love, compassion, forgiveness. I fear that I have not connected the dots as well as I intended, but that's the best I can do for the time being. Perhaps as specifics are brought up I can offer more insight. Thanks for your interest!

I think the big problem is that we, as a species and a society, use logic and reason as our primary means to communicate. When someone has a mental/psych issue we have lost our only means to convince someone to behave as we want them to. What we fail to realize is that our reality is different from theirs. Imagine someone trying to tell you that the computer right in front of you does not exist. This is the exactly what you are trying to do to someone who is schizophrenic when you say their paranoia and delusions are not real. The same is true when you are trying to tell a depressed person that life is good or a person having an anxiety attack that there is nothing to worry about. The body and the senses have deceived the mind. We can no longer use our intellectual capacity to diagnose or our ability to intervene as our purpose. We must become unconditionally compassionate. I think this forces us to step out of our egos and realize we are weak and ill-equipped. Compassion is a lot harder than problem solving.

I'm going to be honest, I did not read the entirety of everyone's posts, so excuse me if I step on some toes. I'm also going to try to keep this brief... 1) The "slippery slope" argument is a LOGICAL FALLACY and should not be used. 2) Define "life". It is very difficult, but as soon as we take the reductionist view, that it is the sustaining biological processes, then you have completely sidestepped the very "essence" of life which you were seeking to protect. Thus it is necessary that we impose some other parameters on our definition of life - quality, capacity, legacy, etc. And from this we end up drawing a conclusion that assisted suicide is ethical. 3) I haven't seen any specifically, but if someone is opposed to a physician assisted suicide because of a Christian perspective, I can offer some interesting ideas that might make you a little more comfortable with it from a religious point of view. I wont bring them up unless specifically asked because it can quickly derail this thread. I think that's all I've got for now.

chbare covered the pharmacology which was the root of your question, but I am going to play devils advocate...just because I can. Based on the formula for normal blood pressure of [(Age x 2) + 90 = 102], and hypotensive being [(Age x 2) + 70 = 82] I am going to argue that she is normotensive. She does not have any hives or angioedema. It sounds like her symptoms are localized to her bronchioles...making me lean away from anaphylaxis. Her heart rate and her respirations are elevated which should be expected from her respiratory distress. She has a history of asthma but no history of allergies (other than seasonal -- does anyone know if there is a correlation between these and anaphylactoid reactions?) You said that she had a "bug bite" which I take to mean something entirely different from a HYMENOPTERA STING. One of which is a leading cause of anaphylaxis, the other I don't believe carries such a risk. In terms of the contrast in onset between asthma and anaphylaxis...well...I can't quite come up with an argument for that. But I think my case still stands. So I'm going to say that your working diagnosis wasn't as wrong as your instructor may have suggested, even though he had the "answer" in his hands and had the advantage of building things around it. Now I ask you...so she was maxed out on albuterol, but what other medication could you have given that has a mechanism of action that is still pretty specific to the bronchioles?

MikeyMedic is spot on. Simple supply and demand. 1) Decrease supply - Make it more difficult for people to get into the field and stay in the field. How do you do that? Increase education requirements. 2) Decrease supply - don't work extra shifts. We all do it because we need to make ends meet, but we are screwing ourselves in the long term. 3) Increase demand - somehow we need to affirm our place in society. Nursing has done a great job with this by having minimum staffing requirements with JCAHO. Fire departments have done a great job with this by NFPA standards (which there is not a single piece of literature to support, yet they still get it passed into standard and get insurance companies to back up the financial end). How do we do this? I'm not quite sure. In the past we have leaned on response times but in the end this result is just a smattering of undereducated EMTs and a paramedic on every piece of fire apparatus rather than system improvement. So what it comes down to is pressuring government officials in favor of regulation that benefit us. I remember a post in a previous thread about the failure of unions for prehospital care because none will take a firm stance in fear of alienating fire-based and low-standard services and losing that revenue base. But why are we letting this stop us? How many people here have complained about the situation of EMS? Now how many of those people have taken it upon themselves to effect change? How many have contacted local, state and federal officials? How many have written letters to their elected officials? How many have been willing to contact news agencies and tell of our misery and woe (think of how scandelous a story it would be reporting that the people in the ambulance require less education than the barber cutting your hair)? I assure you the answer is not many. The problem is we like to complain to each other but we don't get up and do anything about it. We are unhappy...but not unhappy enough. We need the anger. We need the outrage. That is what will produce change. What is the problem...We are the problem. We and our apathy.