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.

Joshua Benton, we use it quite a bit on sedated and intubated patients in our ICU. I have had good experiences with propofol and it is fast acting and quick to wear off. The most common side effect that I have experienced is hypotension. Check out the following link to an entire thread on propofol.

http://www.emtcity.com/phpBB2/viewtopic.ph...opofol+seizures

If I remember, Spock posted some good stuff on propofol.

Take care,

chbare.

"You should try one of those 'Dial-A-Nurse,' Hotlines, i hear they are skilled at finding all sorts of things that don't exist...

ACE844"

ACE844, we had a semester of "finding things that don't exist" in nursing school and even did a 300 hour clinical rotation in the Land of OZ to compliment our didactic education.

Take care,

chbare.

Ace844, results of Dix-Hallpike testing? (rule out any history of cervical spine disorders prior to performing this test)

Take care,

chbare.

Ace844, the RBC's are a little elevated but everything else pans out. Several things to consider:

1)Menier's disease

2)Labrynthitis

3)Syphilis infection involving the inner ear

4)Lyme disease

5)Inner ear tumor ie acoustic neuroma

With a history of HPV it is possible for her to have other STD's.

-VDRL?

-Hx of tick bite or living in an endemic area?

-Hearing loss?

Take care,

chbare.

She has a sodium of 120! Better watch out for seizures. This may be from the N/V and no PO intake times 16 hours. Any C/O tinnitus? I cannot rule out labrynthitis. We need to place a foley and monitor I/O and send a UA to the lab. Manual diff on the CBC? I would also like an ABG and along with that ABG a carboxyhemoglobin level. Continue with the fluids and oxygen and reassess after the liter bolus.

Take care,

chbare.

Mediccjh, I am still holding out for "Traumasurgenocaine for IV injection."

Take care,

chbare.

I do not know what you guys are talking about. All of the patients that come to my er by EMS have insurance. "Self pay" is a form of insurance, right? :roll:

Take care,

chbare.

Ridryder 911, "just a fancy Dextran" is a good description.

Take care,

chbare.

Ridryder 911, I have heard about using HSD for trauma. I tend to think that you are "robbing Peter to pay Paul", however, there are findings that seem to indicate the HSD may be more effective than using isotonic crystalloids. Here are some links to more information on HSD.

A couple of the links may require you to pay to view the article/study.

http://www.medscape.com/viewarticle/461437

http://erj.ersjournals.com/cgi/content/full/20/4/965

http://www.ncbi.nlm.nih.gov/entrez/query.f...p;dopt=Abstract

http://ajpheart.physiology.org/cgi/content...act/290/4/H1642

http://content.karger.com/ProdukteDB/produ...ename=48900.pdf

http://www.aast.org/00abstracts/00absPoster_083.html

Take care,

chbare.