chbare

I believe over aggressive fluid management causes more harm than good, (hemodilution, blowing out clots, messing up clotting factors) This is especially true in the patient who has internal noncompressible bleeding. However, it is nice to have an IV started with blood tubing so PRBC's can be rapidly infused if needed. A saline lock is nice for a secondary or third IV site.

Take care,

chbare.

Nice job everybody!! He does need IV fluids and his renal status needs close monitoring. His labs and UA indicate Rhabo.., a complication of NMS. He needs a foley, fluids, and diuretics to prevent renal failure. 12 lead shows sinus tachycardia. Good job on catching the sux A potential side effect of sux in addition to hyperkalemia (especially with renal failure) is malignant hyperthermia. I hope everybody had fun with this scenario.

Take care,

chbare.

Scaramedic, I have been hearing allot about the new testing. I hope it works out.

Take care,

chbare.

AnthonyM83, no ECT available, but you have your labs. The patient is recieving NS via IV and per a prior post he was given a bolus to increase his B/P. You have got you labs per above and the CT is negative. Dopamine agonist meds are on board. This is a tough case. In fact this was the first thing I experienced during my first day of my first psych rotation in nursing school.

Take care,

chbare.

AZCEP, the patient is given etomidate and vercronium iv and intubated with a 8.0 ETT 23 cm at the lip. No epigastric sounds and bilateral lung sounds with good rise and fall. You use capnometry and an esophageal intubation detector as secondary confirmation devices. His sats increase to 100% with PPV and you notice is is much easier to bag now that he patient is paralyzed. IV fluids are bolused and his B/P remains around 110/50, pulse decreases to 105-110 and strong. You also give a benzo of your choice for ongoing sedation. ( why did we not use succnyl... during the intubation?)

CBC-normal except a WBC of 13.8 & neutrophils of 9, SMA 12; Potassium- 5.9, Sodium-133, Chloride- 92, BUN 35, Creat 2.1, BGL 129, and all others WNL. ABG indicates metabolic acidosis. Tox screen is negative. You also decide to run a Ck & myoglobin- Both are very elevated and UA indicates myoglobinuria. CXR is clear with proper ETT placement noted.

What do you think.

Take care,

chbare.

AnthonyM83, Good, we are working on getting his temp down. Unfortunately, a severe episode of NMS like this is going to need definitive care. There is a high possibility that he may develop a problem that is usually associated with severe dehydration and crush injuries. Your driver takes a wrong turn and now we are in the land of OZ. You have a magic ambulance with all of the ALS supplies and meds you could ever think about giving. In addition you have full laboratory capabilities. What do you want to do about his airway, and what other treatments and tests would you like?

Take care,

chbare.

TechMedic05, correct you got the diagnosis. NMS is a rare complication of neuroleptic medications such as haldol. (especially haldol) I believe it occurs in up to 1% up people who take neuroleptics. It can occur after the fist dose of medicine or in someone who has been on the medication for several years. The syndrome is thought to be a result of dopamine antagonization of the nigrostriatal pathway. Hyperthermia is thought to be a result of a blockade in the hypothalamus. S/S include muscle rigidity, (lead pipe rigidity) severe hyperthermia, altered mentation, and inability of the autonomic nervous system to adequately regulate hemodynamic status. (B/P, and HR will not be WNL) How will we treat this patient?

AnthonyM83, you are doing good, this is a nightmare call for the EMT-B.

Take care,

chbare.

AnthonyM83, you notice that in addition to his contracted board like appearance, his chest wall muscles and jaw muscles are contracted and pretty tight as well. You do not insert an OPA because of the clenched jaw. The Nurse also tells you that the patients temp is up to 106 F. You continue bagging after repositioning the airway, but note it is still very difficult to bag the patient.

AZCEP, you establish an IV and administer 25 mg of benadryl IVP. You do not note any significant change in the patients condition.

On a side note; your transport time to the ER is 30 minutes.

Any thing else?

Take care,

chbare.

PRPGfirerescuetech, I cannot speak for FireGirl911's education, but I graduated from a New Mexico approved EMT I course in February 2006. We were able to take the NREMT-I/85 written and practical exam. (and had too for the military) The anatomy, physiology, and pharmacology was pretty basic and the course was about 216 hours long. It was designed for Army National Guard Medics so it may have differed from the standard New Mexico EMT-I curriculum, but it was still a NM approved course.

Take care,

chbare.

Dustdevil, I could not have given any better advice.

Take care,

chbare.

The NCLEX is set up a little differently that the NREMT exams. Like the NREMT the goal of the NCLEX is to test someone to a minimum competency level. As you take the exam the questions get more complex and head toward the set minimum competency. If you start answering incorrectly, the questions become less complex. This game of getting more complex as you answer correctly and less complex as you answer incorrectly goes on until it is determined that you can consistently answer questions correctly in the minimum competency level or you cannot answer questions in the minimum competency level. One that is determined the computer will stop spitting out questions and you are done. This can be as little as 75 questions or over 200 questions. You are not graded on a percent correct, but solely on you ability to achieve the minimum standard for competency. It is a little complicated, but I hope that helps.

Take care,

chbare.

Sorry I did not post earlier, I worked last night and slept in a little. Thanks ERDoc for not giving it away. No Botox injections, he has received Haldol in the past without problems, no Hx. of TCA use, 02 Sat on room air is 86%, BGL-129mg/dl, B/P-80/44, Pulse-110-130 and weak, and a rectal temp is 105.3 F.

The nurse is a new grad LPN and stated that about an hour after giving the Haldol injection she found the patient like this, she thought he might have had a seizure and called 911.

You insert a nasal airway and begin PPV with a bag valve mask at 15 LPM, you note there is a lot of airway resistance and it is very difficult to bag the patient.

Anything else?

Take care,

chbare.

The scene is secure and you are met at the door of the lock down unit by the patients Nurse. She tells you that the patient is a known schitzophrenic that has auditory and visual hallucinations he has been off of his meds and was admitted having hallucinations and behaving violently. The Nurse tells you that the patient has no allergies, no history of a seizure disorder, and no surgical history. He was given an injection of Haldol about an hour ago then developed what the Nurse thought were seizures. General impression finds the patient supine on the floor without evidence of trauma. You do not notice any tonic clonic activity, but the patient appears to be very stiff and board like. He has snoring and shallow respirations at about 10 per minute. He has a weak thready radial pulse at about 110. His skin appears flushed and feels hot to the touch. His eyes are closed but he moans and grimmaces with painful stimuli. What else would you like?

Take care,

chbare.

You are called to an inpatient psychiatric unit for a 63 year old male having seizures. What would you like to know?

Take care,

chbare.

Ridryder 911, I agree. The concept of EMS as a profession is long overdue.

Take care,

chbare.

Ridryder 911, I agree that credibility and reciprocity are two very strong advantages of the registry. I do not advocate doing away with the registry. I believe that they are probably the best organization to issue a national exam. I just think that every state should require everybody to take the same national exam. That way, at least everybody has been tested to a known minimal competency level regardless of where you took your course. Some day I would like to see Paramedics as licensed professionals and EMS officially recognized as a profession.

Take care,

chbare.

1EMP-P, I agree in a national board exam. Paramedic should be a 2 year program at a minimum and the Paramedic would be a licensed health care provider.

Take care,

chbare.

It will be interesting to see how the easy IO works out. The US Army went with the FAST and I have to say that I love it. (Easy access in seconds) I also agree that most people only report pain comparable to a peripheral IV, but the actual infusion of fluids into the bone cavity causes more pain than a peripheral infusion. I agree with the other posts that IO technology is the way to go. I have limited experience with the BIG and I believe the Army considered using this device, but went with the FAST because the sternum is much less likely to get injured in combat. (Body Armor)

Take care everybody,

chbare.

Battlemedic 345, check you email.

Take care,

chbare.

I support a nationally recognized exam that tests everybody at a certain level. Like Dustdevil, I see schools or even individuals crank out EMT's that have little to no clinical competency, and at least testing every student to a nationally set competency level could help improve quality. I think the national registry has a process in place for testing. (psychomotor and written) The registry has it's flaws, but the NREMT has more experience in testing the NSC, so I think the NREMT is probable the best vehicle for delivering a nationally recognized exam. (after changing the testing process) In addition, I agree with increasing the course length. I have and still advocate learning in a college environment where students must take English, A&P, and science courses in addition to their core emergency medicine courses. Teaching would be done by qualified teachers with an appropriate education background. I also advocate a well developed clinical experience. I see EMT's with as little as 16-24 hours of standing around watching people work in an ER providing front line patient care in an ambulance. I am going a little off topic here but, you are in the back of an ambulance treating a patient. You do not have a doctor with you telling you what needs to be done. You may or may not have medical control available to help you. There are many times where EMT's are independent providers, you are making decisions based on your training, experience, and background. That is allot of responsibility and 110 hours followed by a cheesy test just does not cut it.

Take care everybody,

chbare.

Unfortunately, we must accept that some people will think what they think regardless of public education, high standards of professionalism, and above par health care delivery. A little off topic, but a funny story in any event. I took care of a guy who limped into the ER holding his gut and screaming like somebody put a 12 ga slug through his abd. He had a barium study done several days prior to ER arrival and failed to follow his post procedure instructions. Can we say large solid mass in the colon. Unfortunately, you can guess how I ended up clearing his little problem. Once the problem was clear I ended up having barium stained stool all over the floor, bedside commode, and my entire arm. After helping the guy clean up, mopping the floor, and washing my self up, I gave the now very much relieved patient his discharge instructions. As the guy was leaving the ER he look right into my eyes and said, "Nurse, I want you to personally thank the Doctor for taking such good care of me and making me feel so much better." :shock:

Take care everybody,

chbare.

CD: celestial discharge.

Take care,

chbare.

Firemedic78, I think allot of the resistance regarding EMT-I's and advanced procedures is based on the observation that allot of EMT I programs just do not teach enough background and physiology regarding performing these procedures. I cannot speak for your training, but I know there are several state certified EMT-I programs that are about 100 hours in length and popping out people who are performing very advanced procedures. In New Mexico we have people with under 300 hours of training pushing EPI, Benadryl, Promethazine, Narcan, Dextrose, Monitoring potassium, and giving beta agonist nebs. Even the I-99 NSC only recommends 300-500 hours of training. I do not want to imply that any EMT-I is stupid or not capable of learning these procedures, It's just that from what I have seen and experienced EMT I programs are inadequate at teaching people to be competent ALS providers. I would also bet that many of the paramedics on this site believe that most of the current paramedic programs are inadequate as well. Again, I do not want to imply that anybody is inferior or unable to learn.

Take care,

chbare.

Mountain_Man, I am sorry to hear that. I think CHP medic has a good idea. I know that national parks hire nurses for seasonal work, and the same is probably true for EMT's. Yosemite sounds like a pretty busy place, or you could look in my home state for medical positions at Yellowstone. If you want to go full time law enforcement, you may want to check out Border Patrol. I know that they have BORSTAR teams that specialize in search and rescue. It would take a while to work you way into this position after the long hiring process, the academy, and the probationary period as an agent.

Hope this helps.

Take care,

chbare.

Mountain_Man, have you considered the military? I have trained with several PJ's and search and rescue is their full time job. We have a National Guard medical aviation unit in my state that is very active in wilderness SAR and I imagine there are other similar units in States that have allot of wilderness and national forest land.

Take care,

chbare.