chbare

I want to do something a little different. In this scenario you can have all of the diagnostic tools and cool guy procedures, however, I would like you to give the rationale behind the tests and procedures you perform. For all of you BLS providers, this scenario can be solved if you use some of the most important skills out there. These skills are not beyond the scope of a BLS provider. Here goes. You are dispatched to the scene of a 29 year old male who complains of feeling very tired and weak with bilateral knee pain. What would you like and why? Take care, chbare.

Msmedic_student, welcome to the city. Ridryder 911 has given good advice. AHA puts out guidelines and many physicians do not necessarily follow these guidelines. Be flexible about what you learn and do not get caught up in that follow the algorithm blindly mentality. The term Betty Crocker medicine comes to my mind. Good luck in your education and I hope to hear that you get to put a paramedic credential on your "I love me wall." Take care, chbare.

Windsong, not really a whole lot of diving where I live, however, I have a link to an article on a diving disaster. This is a great account of the life and death of David Shaw. I believe that to this date he holds the record for "deepest dive on a rebreather." The article also describes an incredible account of Don Shirley's (David Shaw's friend and dive buddy) quest for survival in the depths of the cave. EDIT: You are correct about disaster occurring when you least expect it. The scary thing about diving is you are totally isolated from the terrestrial world. You could be in danger and only 80 feet from the surface, but you may as well be orbiting Alpha Centauri. http://outside.away.com/outside/features/2...ave-shaw-1.html Take care, chbare.

Ace844, we are not. We do not even have a cath lab...yet. Take care, chbare.

We use TPA at our facility as well. In fact I just administered TPA to a 36 year old patient who presented with sudden onset right sided paralysis and facial droop. The results were quite profound. The patient gained nearly all base line motor and sensory status back. CVA education is pretty poor in our area and most strokes do not get to the hospital in 6-8 hours let alone 3 hours. Take care, chbare.

Mysticlakecasinoemt, hmmm, bad ju ju to let somebody work a patient on word alone. I am with Ridryder 911 on this one. Check credentials, have that person talk with your medical control, and then document your butt of about how that person took personal responsibility of the patient. (if medical control even agrees to let the person ride) I also agree with Vs-eh?. I cannot understand why somebody would refuse to let the crew take over patient care? What am I going to do with my nursing license? Use it to stuff into a bleeding wound in the hopes that it will stop the blood loss because I do not have all of the gear required to treat somebody in the field? Unfortunately, I have been at the scene of a few accidents and incidents and I am more than happy to let the crew take over unless they specifically ask for my help. In addition, the only time I have ever told anybody I was a nurse was when a person was hit by a van in front of me while out walking. I told a bystander that I was a nurse and borrowed her cell phone to call 911 and call the ER directly and give them an on scene report while I rendered first aid so they could prep the trauma room. As soon as the Paramedic crew arrived, I gave report and got out of their way. Take care, chbare.

Medic53226, sounds like a train wreck..err..ran over by a tractor wreck. Did the patient have a flail chest with all of those rib fx's? I would also suspect a pneumo and or a pulmonary contusion. This guy will be in for a long recovery. Did our treatment and assessment techniques differ from yours? Take care, chbare.

Medic53226, it looks like we may have a pelvic fracture in addition to all of his other injuries. The question now is, where to go. This guy needs trauma care and a trauma surgeon. I am leaning toward the level III. (unless I can get him to a trauma team faster by going to another hospital) Load the patient with spinal precautions and take measures to maintain a regular temp. Pelvic splint device if available. Is this ILS or an ALS unit. If I cannot take measures to manage the airway (if it comes to that), I would also call for an intercept. I would give some fluid as well. (500ml bolus and frequently assess. The last thing I want to do is raise the B/P and blow out clots. The whole Fick principle thing again.) Take care, chbare.

Medic53226, -Do we have air evac resources? -Does the local hospital have any surgical abilities? -Is the patient having notable dyspnea? -Belly soft and non tender? -Back exam findings? -Pelvic pain or instability? We need to get this patient on high flow oxygen and obtain vascular access. The lower left rib crepitus and hypotension is a very high index of suspicion for a splenic injury. If this is the case, dumping crystalloids into this guy will not help. We need to get him to a hospital with surgical capabilities. It also sounds like he has a left sided pneumothorax. Depending on what we are allowed to do, I would dart the chest. (Low o2 sat, low B/P, Tachycardia, and cyanosis along with the crepitus and diminished lung sounds-> tension pneumo until proven otherwise in my book) If there is no improvement with the dart, then I would think he has a significant vascular injury. Take care, chbare.

-General impression of the patient and scene. -Identify any hazards. (Animals, the tractor, weather, etc.) -Ascertain the need for additional resources and make sure there is only one patient. (Is this guy so tangled up in a fence that we may need help cutting it away from him, or is he impaled and we need to do some cutting to free him from the object?) -Where is the closest trauma center and how far away is it by air and ground? -Do I have air evac resources? -What is the weather like? (Is this guy going to freeze or burn up?) Then the general primary assessment stuff. ABCDE's and the rapid trauma survey with c-spine precautions. Specific treatments based on the above findings. Take care, chbare.

I agree that this is a very deep philosophical question. My opinion on the whole "lifesaving business" is based around my belief that we humans have very little control over life and death. I think that we play a role in promoting life, but the final decision is up to somebody or something with power far beyond my ability to comprehend. In addition, I agree that we play a role in helping family and friends through the traumatic process of death and disease, and we play a role in helping people live and die with dignity and comfort. Take care, chbare.

Dustdevil, thank you for the update. Take care, chbare.

I have been called orderly more times than I can remember, even though I always introduce my self as a nurse and I have to wear a name tag with big black letters that say nurse. I am more amused than annoyed by this. Take care, chbare,

Good discussion. We try to avoid hyperventilating our head injury patients if at all possible and focus on adequate oxygenation. Asysin2leads, I have seen beta blockers used in a few head injured patients and nontraumatic ruptured berry aneurysms. Ridryder 911, thank you for the link. I know some people may be put off by my land of OZ progressive ambulance stuff, but I like presenting a scenario all the way to the diagnosis and definitive care. I hope it helps people appreciate the big picture and the pathology behind the problem. I always want to know what happens to my patients after they leave the ER and their eventual outcome. I hope this way of looking at health care leads to a greater understanding of the diseases and injuries that I encounter. I try to include the EMS and in hospital aspect of my scenarios. Let me know if I need to spend more time focusing on the EMS aspect of my scenarios. Take care, chbare.

AZCEP, you nailed it! History of an acceleration/decelleration MOI, sustained coma, and a normal CT scan. (many times DAI will present with a normal CT and MRI will be used to detect the lesions) This person will probably not recover. Here is a link if anybody would like more information on DAI. http://www.emedicine.com/radio/topic216.htm Take care, chbare.

Hammerpcp, I sure hope he's not pregnant. Then again you never know. I forgot that BGL's are in mmol/L where you live. A BGL of 130mg/dl is about 7.2 mmol/L. Lets say that you tuck your patient in for the night and in the morning he remains unresponsive and the repeat CT is negative. What do you think? Take care, chbare.

I am sorry I overlooked this. ERDoc mentioned getting some scans and I did not give you guys that up date. Here is a non contrast CT of his head. For the sake of simplicity lets assume that all of the other slices follow what you see on this slice. Take care, chbare.

I think hemopure has seen allot of use in South Africa. I will try to do a little research and post with an update if I find anything. Take care, chbare.

Hammerpcp, no medical history on this patient. UDS is positive for meth and his ETOH level is 230mg/dl. I agree he is not presenting with signs of tension pneumothorax and I would consider holding off on immediate needle decompression, however, with your ultra progressive ambulance, you could always consider a chest tube. Current V/S; P-88 reg, RR-14 with PPV, B/P- 170/89, O2 sat-100%, Temp- 100.6 F. There was allot of broken glass inside the cab, and this may explains the abrasion and lacerations. Are there any tests or procedures you would like to perform? Take care, chbare.

ETCO2 shows a good wave form with values around 36-38. CXR shows good tube placement, normal mediastinum and cardiac outline, you note a pneumothorax to the left approx 30-40%, diaphragm appears intact. Trauma C-spine and pelvis X rays are negative. Take care, chbare.

TechMedic05, lung sounds per prior posts. O2 sat is 99-100% while bagging the patient on 100% FIO2. No seizure activity noted, no vomitus, and no trismus noted. The patient appears to be flaccid. Take care, chbare.

TechMedic05, good catch, need to finish up our base line vitals. The B/P is 160/090. Take care, chbare.

PRPGfirerescuetech, pupils are 4 bilat and sluggish to react. You get the patient loaded and intubate him with an 8.0 ETT placement is verified with ETCO2, the lung sounds on the left side remain diminished however. You continue bagging him. You have a vent and can set the vent values for whatever you fancy. A large bore IV is established with blood tubing attached and 0.9 % saline as your fluid. You put him on the monitor and note a sinus rhythm of 95 without ectopy. You begin transport to the hospital and notice that the sun is out, the birds are singing, and the land scape takes on a surreal appearance. It must be the land of OZ and you now have a very progressive ambulance service. What would you like? Take care, chbare.

The patient is exposed and spinal immobilization is maintained. If we follow PRPGfirerescuetech's airway management techniques then; an oral airway is in proper position and your partner reports he is able to bag the patient and a firefighter helps maintain the mask seal. You note chest rise and fall with ventilations. The patient remains unresponsive. You are able to palpate a regular radial pulse at about 100. The patient appears less pale with bagging. If we used the combitube; your partner states he is able to bag the patient through tube number 1 and placement is verified with ETCo2 monitoring and the patient appears less pale. The patient still remains unresponsive. A quick back exam is unremarkable as you rapidly move the patient on to the board. Your secondary survey reveals: HEENT; several small abrasions and lacerations to the face and scalp with minimal bleeding, no crepitus noted, airway is patent, pupils are about 4 and sluggish bilat, no drainage from the nose or ears noted, trachea is midline and slight JVD is noted, bilat carotid pulses at about 100 and regular are palpated, and no c-spine step offs are palpated. CX; a few small abrasions are noted over the left upper chest wall with the beginning of what looks like developing contusions, this looks consistent with hitting the steering wheel or the wheel hitting him, and he was trapped in part by the wheel, no crepitus is palpated, lung sounds are clear on the right upper and lower, and diminished on the left. ABD; atraumatic in appearance and soft to palp in all quads, and no surgical scars are noted. GU/Pelvic; atraumatic in appearance and stable to palpate, no GU abnormalities noted, and no rectal bleeding or blood at the meatus noted. EXT; atraumatic appearing lower ext with palpated distal pulses and no crepitus noted, several small abrasions to both elbows and forearms, no crepitus or deformity noted, and bilat distal pulses are noted. Take care, chbare.

My service just purchased one and in spite of the shortcomings, (heavy, battery life, potential frail components) my back loves it when we have those 300 pound plus patients. Take care, chbare.