chbare

Medic 429, you nearly go it, good thinking. JackMaga, you nailed it. This guy has Toxocariasis, a type of round worm infection. Here is a link for some more information on Toxocariasis. http://www.emedicine.com/med/topic2293.htm EDIT: I will explain the very basics of the CBC findings just so people who are not exposed to labs can see what we were talking about. WBC= White blood cell count. This number is usually between 5,000-10,000/cubic mm of blood in the adult. So, 13,000/mm3 is on the high side. An elevated WBC indicates something is activating the immune system. (stress, trauma, infection, allergy, etc.) Now, we look at the different types of WBC's. There are 5 basic types of WBC's. I gave the relative value of the 5 types. That means I broke it down into percentages. Normally Neutrophils take up 50-70% of the total WBC -Lymphocytes- 25-45% -Monocytes- 2-6% -Eosinophils- 1-4 % -Basophils- 0.5-1% Neutrophils- their mechanism of action includes phagocytosis and activation of fever. An elevation in these cells may indicate a bacterial infection. Lymphocytes- their mechanism of action is based around antibody production. An elevation may indicate a viral infection. Monocytes- These cells are the second line of defense against bacterial and viral illness in addition to phagocytosis of large protozoa such as fungi. These are thought of as the scavengers that clean up the field after the battle. Eosinophils- the roll of these cells are not well understood. May be involved in the activation of histamine. These are elevated during an allergic reaction or parasitic infection. Some cancers can cause elevations as well. Basophils- the roll of these cells are not well understood as well. They may play a role in allergic reactions. This is the very basic info, so I will not talk about granulocytes vs agranulocytes, bands, or segs. Hopefully this was helpful. Good job on this scenario everybody, it was a rough one. Take care, chbare.

Janmarie3, you may want to think about working for another employer if you think your current employer is so pathetic that they must hire and retain people who are unprofessional. It also sounds like there are other things going on as well? Take care, chbare.

Systemlord, (9 months pregnant + seizures = eclampsia unless proven otherwise) (eclampsia = emergency). How could you not consider this an emergency? I am not looking to pick a fight, however, I am very curious to hear the rationale behind why this patient was not considered emergent. Eclampsia is an emergency in a hospital with definitive medical and surgical care, let alone a hospital that must send their patients 100+ kilometers away for definitive care. The sequela of eclampsia can include; intracranial bleeding, liver failure, abruptio placenta, retinal hemorrhage, renal failure, pulmonary edema, fetal hypoxia, hypofibrinogemia, and both maternal and fetal death. The fetal mortality is 25% and the maternal mortality is 10%. In addition, you have two patients. Take care, chbare.

I agree with Ridryder 911 on Critical Care Paramedic. I think this book sets a new standard and covers material in much more depth. Another book I love is Rosen and Barkin's 5-Minute Emergency Medicine Consult . Very well designed and easy to read. The diagnoses are presented in column format starting with S/S, clinical features, and physiology. Prehospital considerations all the way to admit criteria are covered as well. Take care, chbare

AZCEP, try a WBC of 13,000/mm3. (I cut the zeros off, sorry if this was confusing) What do you think of the eosinophils? Edit: The flat and upright abd is negative. (nothing major such as, air fluid levels, free air, or evidence of ileus) The gallbladder US is negative. Take care, chbare.

Joshua Benton, you cannot hold your self accountable for you former partner's actions. It sounds like he was well on his way to self destruction prior to you informing the supervisor of his actions. Take care, chbare.

You get blood to the lab and they start cranking the results out. Unfortunately, the CT scanner and chemistry machines go down and the only thing you can get is a CBC. Hey, even the land of Oz has the occasional problem. EDIT: Cannot get a VQ scan in until the morning. WBC: 13/mm3 Hbg: 13.9g/dl HCT: 47% PLT: 159/mm3 Neut: 45% Lympho: 10% Mono: 2% Eosino: 42% Baso: 1% What are you thinking now? Take care, chbare.

Hammerpcp, the PA CRX does show a small right sided pleural effusion. No history of trauma. In addition to a negative TB screen during his physical, he was also negative for HEP C & B. (not a normal chapter 2 physical, but we are in the land of Oz after all) Are there any tests or assessments that may help you solve this scenario? Take care, chbare.

Mark3743, it is possible. No signs of jaundice noted. If we took a turn into the land of OZ are there any tests that you would want to prove/disprove your theory, or is there something in the history that may help? Take care, chbare.

AZCEP, I agree. If she stabilizes with the IV Dextrose, we need to find out why she has a temp if possible. This sounds like more than a hypoglycemic episode. (other stuff going on) Look at the 5 W's and rule out medications. (Haldol, Thorazine, etc.) Medic53226, were you able to get a follow up on her? Take care, chbare.

Let me try to answer all of the questions. -He has been urinating without any problems and his last BM was this am and he states it was regular. -The chest and back exam is unremarkable with the exception of the findings stated above. -The RUQ of his abd is tender to palp and you do note hepatomegaly with palpation. -No hx of trauma and bowel sounds are noted in all four quads. -No known insect, arachnoid, or animal bites & your exam is unremarkable. -+5 strength and full ROM noted in all extremities, and distal neurovascular status is intact. -The S/S started several days ago and the patient states he has gradually been getting worse. -The patient does C/O occasional chills. -He states his unit spent two weeks in the woods on a bivouac, he is concerned that he did not get enough sleep. Complains about people walking their dogs and the barking keeping hi up all day and night. -no significant change in B/P from arm to arm. -complains of puritus to his arms and legs that comes and goes intermittently in addition to his other complaints. I hope this helps. Take care, chbare.

Medic53226, No drugs Rx or otherwise, no known history of gall bladder problems, he is tall and thin however. He asks you if you think all the time he spent out in the field on his exercise a couple of weeks ago could have contributed to his illness. Take care, chbare.

AZCEP, Nice, I like the "Wonder Drugs" part as well. Take care, chbare.

Systemlord, not all Nurses panic in an emergency. I work in a rural ER and I can honestly say that the nurses and EMT's that I work with are top notch. I think that perhaps training and regular practice would help rectify the problem. Nursing school education focuses on a very broad range of knowledge, theory, and patient care techniques. I would not expect an entry level nurse or an untrained nurse to step into an emergency like this and function perfectly. Just like I would not expect an entry level paramedic to assess and treat an infected stage III decub without additional education. Nursing is like any other area of medicine, you must practice and continuously keep your skills and techniques up. Take care, chbare.

Lets check a temp as well. I would hold on lactulose until we can get labs and a NH3 level. (elevated NH3 can defiantly cause altered LOC) I agree that we are potentially looking at sepsis. Any body remember the 5 W's of infection after a surgical procedure? Also agree that we need a BGL. We need to do a more detailed head to toe physical assessment and pay special attention to her ABD. In addition, we need to look for S/S of internal and external bleeding. Take care, chbare.

Since the ABC's are covered, I will allow for a progressive ambulance. Take care, chbare.

Ridryder 911, he had a TB test done about 1 month ago by the National Guard prior to a short term deployment on a training exercise and it was negative. He states CA does not run in the family. Take care, chbare.

MrSpykes, monitor shows sinus tachycardia without ectopy. You administer 2.5 mg of albuterol via LVN and initiate vascular access without incident. Pupils are PERL and brisk to react, EOM'S are WNL, no indications of trauma or pathology noted upon external exam. the rest of the HEENT exam is unremarkable. You note that the patient does have a dry cough however. The patient reports feeling a little better after the TX and the wheezing clears, however, lung sounds remain decreased in the RLL. The patient continues to complain of generalized weakness and abdominal pain. Anything else? Take care, chbare.

Medic53226, sounds like this patient is very ill. No hazards noted during our assessment of the scene? What are our resources? (BLS,ILS,ALS, nearest hospital and what facilities, helo) Need to get her on high flow O2 and do a respiratory assessment. (effort, accessory muscle use, lung sounds, obstruction-->snoring could be the tongue ) Are we able to manage her airway with BLS? We may need to intubate her for airway management based on our assessment. What exactly is her mental status? What is her pulse rate and quality in addition to temp? Need to quickly find out if she is allergic to any meds and her medical/surgical history in addition, we need a medication list. Further interventions will be based on our assessment of her ABC's. Take care, chbare.

NYAEMT-I, He feels weak all over and states he has been coughing allot and has a little abdominal pain. He states his symptoms started several days ago while at home. His medical history is significant for smoking (1 PPD times 6 years) and he states he drinks about a case of beer per week. He is allergic to PCN and denies any other medical problems. V/S 133/88, P 107 strong and regular, RR 22 states he has some chest tightness, O2 SAT 94% R/A, Temp 100.3 F. You note wheezing throughout all of his lobes and decreased lung sounds in the right lower lobe. His RUQ is tender to palpation when quickly assessed. BGL is 119 mg/dl. Take care, chbare.

You are called to the residence of a 22 year old male who is not feeling well. What would you like to know? Take care, chbare.

Bub, I was making about $6.00 per hour in the late 90's as an EMT-B. (No benefits) This was just prior to selling my soul to the dark side. You can imagine how elated I was when I received my first pay check following official employment with the dark side. On a serious note, full time EMS can be pretty rough on the family life, and yes you should expect to work insane hours and strange and unusual shifts. It sounds like you have a college degree? Depending on your degree, you may want to consider nursing school. As a member of the dark side you may be able to work in an area where you can have a family friendly schedule. One of those areas is long term care. I worked in a NSG home as an LPN for about a year, and I can say that I loved my job. I worked 8 hour shifts, (could work 10's or 12's if I wanted) met some great people and family members, and learned allot about life, pain, suffering, happiness, and grief. In addition, the pay was pretty good. Not trying to start that old nurse vs medic thing, however, it is just something to consider. Take care, chbare.

Good points on the prehospital application of propofol. It is pretty easy for me to monitor somebody on a nice still bed with equipment plugged in to a central monitor and a more static environment. However, in the back of a bouncing, swerving, rocking ambulance, monitoring the patients hemodynamic status is difficult at best. I would not want to use propofol routinely in the field because you really need instant feed back on these patients. Perhaps with a service specialized in transports and a patient with an art line so I can have instant hemodynamic feed back. Just my opinion however. Take care, chbare.

Ace 844, good scenario and Itku2er, good job. Take care, chbare.

Joshua Benton, bad situation. I would be very careful about sedating head bleeds. You are correct to worry about blood pressure. The goal of our care is to prevent secondary insults, and hypoperfusion along with hypoxia are very common causes of secondary cell injury. Have you considered presenting this patient as a scenario or case study. The background, history, and complete assessment of this patient would give us more information to base our responses. Here is a good article of subarachnoid hemorrhage management. The pharmacology is also discussed in this article. http://www.emedicine.com/EMERG/topic559.htm Take care, chbare.