mobey

When a pregnant woman codes in front of you, and you eventually choose to stop CPR, you must take into account you are essentially choosing exactly the moment her unborn baby will die right in front of you, while under your care.

Sometimes being a Paramedic fucking sucks.

Feel free to turn this thread into whatever you want, I just want those who do what I do, to agree, sometimes our job sucks!

I dunno where I get this but: RuffEMS

I personally have not done the South beach diet, but my ENTIRE family has.

The common feedback was it is good for a short time. They all lost a bunch of weight and got whipped into shape, however, eventually the food preparation got to be too much. The recipe's take a while tto prepare, and some of the ingredients are just not available in our area.

After 6mos they all quit it, and just concentrated on building thier own healthy diet with what was availabe.

No one is mocking you.

We are getting frusterated, and for good reason.

We get alot of patients just like you who do not understand why you were treated the way were and have questions. The problem is, your questions revolve around a seperate agenda, and it is one we are all too familiar with.

Your posts give the impression you were looking to point fingers at these medics, Perhaps that is not the message you were trying to send, but that is the one recieved. When us rounded Paramedics validated the way you were treated (ie; no lights & sirens, possible hyperventilation) you rejected the idea. That only solidifies in our minds, that you are not looking for widespread reasoning or explination, you are looking for validation of your distaste for the way you were treated by EMS.

Well sorry to spoil your pity party, but as EMS professionals, it is not our perogative to judge eachother behind our backs (or at least it should not be, and some still have some professional development to work on).

I realize you are reading medical records, but you should really put them into perspective, do you really expect a Doctor to write "Patient appears anxious" in his notes?..... not likely. But hey if ALL the details were in those charts you would not be asking us questions right?

Then stop rejecting our answers.

You are an educator, you can do better than this.

Hey Doc,

What would be the physiology behind the dyspnea secondary to sepsis without vasodilated pressure issues? Or perhaps there's not an answer there that's easily explainable at a level I'm likely to understand?

I assume by Doc, you meant me?

j/k... I actually just want to jump in here so I can show off a little then get knocked down a peg and learn from our resident doc's

Dyspnea in Sepsis:

During sepsis the patient will present with incresed lactate levels. Lactate is a byproduct of hypoxic tissues utilizing anaroebic metabolism as seen in sepsis. Lactate (Lactic acid) is transformed into C02 and H+ and creates a acidotic state. Because our resiratory drive is based on Ph values in the CSF (chemoreceptors) this stimulates tachypnea in a effort to blow off the extra c02.

Done without refreshing, so excuse the errors.

...that being said I really think everyone should start at the bottom and work their way up.

There is a few errors in that post...swype ruins everything..lol

Silly swype almost made you look like an a$$. Good thing this was a typo......

Panic attack?

Now who is putting words in whom's mouth?

I know that for a fact. I asked about that later and the doctor told me when your heart is beating so fast as mine was at 225 it makes your heart inefficient at pumping blood. Therefore it makes it hard to breathe when you are not getting adequate amounts of oxygen from an inefficient heart.

If your blood pressure was 170/100 your heart was pumping blood just fine.

Increased respiratory rate would be expected in this case, but not 30. I am sure there was a fear factor playing a role here.

I never said I was at deaths door,.

I never said - that you said you were at deaths door.

I said I don't think you were.

I get the feeling you completely ignored the message of my post.....

Thought I would fix this up for ya

Post partum hypertension is fairly common, post partum eclampsia (pre or not) is pretty rare and very nasty. Glad you had a good outcome.

To be fair to the medic(s) your disease process differetial was complex... HOWEVER they may not have treated your symptoms correctly depending on thier protocols or with the urgency they deserved if your presentation was as you posted it here. Some Field medics occasionally get caught up in the I don't have a clue what this is so I guess it's nothing bad cause they didn't teach me about it and we dont have a protocol for it.

What they should be doing is treating you for the adverse symptoms you were displaying IF they had protocol to do so... high fever dyspena, hypertensive and an SVT at >200 in a POST OP patient calls for ALS If ALS is available in your area. On the bright side unless they were complete idiots (and they may be) they learned something that day that might save someone elses life.

Thanks for the intersting case!

Many things can effect the way we transport patients, including distance to hospital, traffic, driving experience, weather. The use of lights & sirens has not been shown to reduce transport times to the hospital in the urban setting. I routinely use them on the highway during critical transport, and shut them off once in city limits.

If this was a Basic life support ambulance in an urban setting, they may have been justified in everything they did, and we as professionals on this site have no buisness armchair quarterbacking thier call.

The fact that you were treated with pharmacologics and not electricity immediatly speaks to the fact you were being treated as a "stable" patient. I fully realize you were suffering mentally, and a HR that high cannot be sustained for too long, however, it appears you were not at deaths door.

It is very common here for EMS to stay and observe in the ER.

When I approached this patient I assumed stroke.

I suctioned her, put in an NPA, nasal cannula, and hit the road.

Enroute to the stroke centre (without surgical capabilities) I started 2 I.V. at TkVo.

12 lead was unremarkable.

I administered 10mg Maxeran IVP

I RSI'd using 100mcg Fentanyl, and 2.5Midazolam. I used Succ for paralysis.

A 7.5tube was placed and confirmed by ausiltation, visualization, bulb, EtC02 waveform and numerical. I immediatly suctioned as far as I could and got quite a bit of vomit out.

Sedation was maintained with 2mg bolus's of Midaz, and 50mcg Bolus's of Fentanyl.

No further paralytics were used, and the patient was not making any resp effort.

A CT scan was done, and showed thrombolytic stroke with significant swelling.

A risk/benefit was weighed as family could not be contacted, and since the mpatient had only a history of glaucoma, TPA was administered.

A chest x-ray showed significant aspiration in the left lung.

Post TPA the patient did not improve, over the next 12 hrs the HR came up, and Bp decreased (normailized), this could be due to a decrease in swelling.

Although I was SURE this was a bleed, I made a pretty good choice by racing to the primary stroke centre to maximize her chances of a positive outcome.

This was a good call to make sure my confidence was in check since bypassing to a surgical site based on my theory this was a bleed would have been the wrong choice, as would a helo.

Thanks for playing!

A small child, perhaps. The story goes, the child who was asked to see if the turn signal worked, responded, "Yes...no...yes...no..."

But as to having the siren blast someone at close range, file that one under HELL NO!

Doing a routine "state speck" (the daily New York State "Part 800" compliance inspection checkout) of an ambulance, I was standing on the door sill of the ambulance, verifying the light bar was working (it was), when my partner hit the siren, as part of the check. My ears were less than 4 feet from the speaker of a 200 watt siren system, and sound is painful at 118 decibels (I'm fudging the figure a bit, as I don't really recall the number), but due to me not being prepared to be blasted, the siren actually knocked me off the doorway, and I was saying, "could you repeat that" most of the day.

Big difference is, my partner did it without malice. What you describe was with evil intent. A siren at that proximity to the human ear has been known to cause deafness.

I also, in disclosure, mention that as a 5 year old, my grandmother took me to see FDNY Engine 268 and Ladder 137. The Fire Fighter put me up into 268's cab, driver's position, where I promptly found the air horn button, used it, and was promptly removed from the cab.

Naa, I am talking about standing out in front looking at a light, not that close of proximity that a small blurp from the siren will do auditory damage. I am goofing, not abusing.

I am a huge fan of the "Watch this light on the grill and tell me if it quits flashing". Then jump inside and turn the flasher on, then quickly hit the siren.

Gets them every time.

What do her lungs sound like? Temp?

Lets give her 20ml/kg bolus and get her to the nearest facility.

Baby can have IV/IO access as well. Need a glucose here too.

Baby gets a 10ml/kg bolus to start (given the sugars are not high as well).

Temp?

Lets give her 20ml/kg bolus and get her to the nearest facility.

Baby can have IV/IO access as well. Need a glucose here too.

Baby gets a 10ml/kg bolus to start (given the sugars are not high as well).

EDIT: Should have read closer

I just wanted to be sure we verified placement with the usual methods before moving on. I assumed Mobey ment the tube was in proper place, but assuming can lead to all things bad.

Sorry, left out an important point.

EtC02 20 initially, good waveform. Sp02 still 98-99%

Yes the tube is above the carina in the trachea.

The moment you start injecting information into a question, you've already been defeated by it.

Love that response!

I guess I should have put a sarcasm smiley next to my "Do they want me to stop at the store?" comment. I mean really! Doesn't everyone have a fully stocked fridge, or, better yet, a cow on their truck??

I work in a different environment I am sure. But I would stop at 7-11 and grab milk if it meant better patient care..... of course remote settings hae different rules.

After a little research....

Ph of a tooth: 6.8-7.0

Ph of saline: 7.4 (same as blood)

Ph of sterile water 7.0

Ph of 2% milk: 6.8

_{So lets go back to before this newbie even attended the call. Did you as a preceptor go through explaining to him/her that when we communicate a pts condition we try to make it so they can understand what is going on and that we try to communicate the condition with out adding extra stress.}

_{New medics are so focused on trying to diagnois what is going on that they forget how to communicate. I have had to train the new one just out of school and they are not really told how to talk to pts, and what they are taught really isnt always real clear.}

I do think we expect this to be established when precepting a Paramedic student (This is U.S.... so NOT Primary Care Paramedic *EMT) This is a basic communication skill. Right or wrong, we do not expect to teach basics to Paramedic students.

Code status is "full code" as she has no past medical history.

Anyone want to comment on Ketamine with suspected neuro problem that may include increased ICP?

Once the tube is placed, the heart rate drops to 28 and BP is 178/102. Pupils are both dilated and sluggish. She is no longer making any respiratory effort.

I'll let a few responses to this change, then wrap this up with final treatment diagnosis and outcome.

Not enough said. Would some kind ALS person tell this BLS person what the (presumed) drug is, what it is for, and what results from it being in Tea?

Happily

Furosemide (Lasix) is a loop diuretic. It inhibits the reuptake of Sodium in the loop of Henle in the kidney. We all know "water follows salt" Therefore, it encourages fluid leaving the body. It also has no discrimination to chloride, calcium, or magnesium either. The body... working to remain at homeostasis.... shifts potassium out to match the new electroyte levels.

So when given improperly (like to a patient who does not require it) it causes, hypovolemia, Hypokalemia, hypomagnesia, hypocalcemia, hyponatremia. All of these are potentially lethal, and will cause the patient cardiac rhythm disturbance, restlessness, polyuria, polydypsia, abdominal pain, nausea/vomiting, muscle spasms, etc etc

/sarcasm: Oh yeah.... the polyuria is hilarious!! sarcasm

Well this lady seems to more than likely have had some sort of cerebrovascular incident since the nursing home fed her. I knew that chicken didn't smell right

I'd call for helo and have them meet us. Rationale?

I'm gonna tube her both to protect her airway and to increase my tube stats.

So what is the difference between your Primary stroke center and your Major hospital with surgery???? I'd Like to know because there is a difference of only 15 minutes. Does the Primary stroke center do surgery or not???? No. We have a unique system out here in the sticks. One of the nearby "health centres" staffed with GP's, has a head-only CT scanner. The scan is read by a neurologist in the city in live time, then the patient is placed in front of a camera hooked to a monitor in the city and the neurologist will assess using the smalltown GP as his "remote arms"

"I'm gonna tube her both to protect her airway and to increase my tube stats." - LOL, I just +1'ed you for that...

I want to take a closer inspection of the throat and neck. I'm assuming the reaction to the OPA was pressure in the pharynx nerves interrupting brain stem function, though (and possibly food causing similar response). No food bolus. That is what I chalked it up to as well

Does her oxygen sat improve with the nasal cannula? Yes 97%

I'll move on to D. Pupils? Any sort of posturing? Pupils small and non-reactive. Now decorticate posturing to deep painful stimuli

Also a quick head to toe exam. Signs of recent injury perhaps. Notta

Go to the stroke center. Rationale?

Try to find out why she's on prednisone (and confirm name of eye drops...they have some crazy meds in eye drop form these days). You can ask her but I doubt she'll answer (Haha... being a dick, I know) As for the eye drops "We" left them in the appt. Hey I never said I was without flaw!

Once intubated she might also be a candidate for hyperventilation...but I'd contact medical control on this. Welcome to my world... There will be no cell phone reception for about 15-20min, then you will have it for about 10min.

Super cool to see you join in Anthony.

What would ya'll like to use to intubate?

Repeat vitals

Bp 150/98 RR 24 deep, nonlaboured

Sp02 97%

BGL 5,4 (normal)

HR 48

I am with all the others, there has to be the right tone.

I am not much of a hand holder, but I can fake it pretty good. I usually offer a "I am sorry you are going through this, we will make it as comfortable as possible", or "I am sorry for your loss"

I have also thrown out: "I know you're thirsty, but I am working on saving your foot right now", and "Your heart is in a lethal rhythm, and we are going to give you some medication to try straighten it out".

I really do make myself the clinical one on a scene, I am not running around giving hugs, I am not raising my voice, or using terms heard on Grey's Anatomy, but if you want clinical information, or someone to remain professional in an emotionally charges situation, I'm your guy.

I don't see much wrong with the student's performance, other than missing the followup info about treatment, given it was presented professionally.

I think it is important to point out that alot of the coping mechanisms seen on scenes (crying, panic, anger, etc) have to do with the unknown. Just giving a diagnosis, and verbalizing a treatment plan relieves alot of anxiety for everyone..... including the practitioners!

While left lateral would normally be my preferred position, I'd like to sit her up in a high-ish Fowler's position for better assessment access.

If airway is clear, I'll attempt a head tilt, chin lift. Check for a gag reflex.

Tell me about her breathing: rate, rhythm, tidal volume, effort.

Based on that, I'll get her on oxygen via nasal cannula or BVM. Avoid a mask in case she vomits again. Additionally what are lung sounds.

OPA is attempted but the patient goes apniec, once it is pulled out, she starts to breathe again. No... not obstructed airway, I mean with OPA in place she does not attempt resperation at all. No gag reflex it appears.

With a NPA, and simple jaw thrust, the patient is taking deep resps at 22/min.

Her air entry is clear on the left, and rhonchi heard on the right throughout. No accessory muscle use.

Circulation: Pulses are exual at the radials, at a rate of 50bpm and strong.

Skin is warm at the core, cool extremeties. Skin turgor is usual for an 80 year old. Pink overall.

Now on the cot, the patient is responding to deep pain with only decorticate posuring.

History and meds are in previous post

Vitals: BP 130/90 HR50 RR22 Sp02 92% (room air)

EtCo2 (nasal sidestream) 20mmHg

BGL 5.1mmol

Here are your transport options

1) Local clinic with GP: 5min away

2) Primary stroke centre (utilizing mini CT and teleconference) 1hr away

3) Major hospital with surgery/ct etc 3hrs

4) Helo rendezous 45min away, then 30min flight to Major hospital.

Why does the facility think they have a norovirus?

There has been multiple care homes/long term facilities in the area with patients testing positive for Noroirus. When nearly a dozen people in this home develop coughs, and feers, the public health officer locks it down under the assumption the same here.

"Crook" means sick like how sick does Nana look

OK so leaning forward with deep snorous respirations; what is her conscious state like? Obs?

She in not responsive to verbal, but localizes pain..... just.

Her vomiting has stopped now. We strip her clothes off and get her onto the cot. What now? positioning? diagnostics?

I know this is a little basic for you adanced scenario responders, but maybe there is a nOob or two out there that could run us through a workup of an unknown unconcious?

As I said in the title... this is no brain buster.

It will be probably be easier to take it back than to look it up. Let me see if I can find it but I am cool and down with the gagging elderly lady.

Ahhh I see the singular pronoun there.

I thought I had a habit of letting down the other forum members here by starting a series of scenarios and then leaving.

I do believe I remember the one you are referencing, no need to look it up. Working remotely like I do, I often get 10-12 hour long calls in the middle of the night that screw up my brain for a day or two which is what happened that day.

Perhaps you did it with tongue in cheek humor... I really can't tell.

Is Nana one the infected peoples? Guess we gotta figure that out

How long has she been vomiting? Hours? days? What's her history like? Any hepatic problems, ulcers, AAAs, diabetes, gallstones, abdo surgery etc? No history given. Last seen eating an hour ago.

What started it? Has she eaten anything different? Dunno! The meal was standard Wednesday lunch, nothing new

What have her symptoms been? What has she been vomiting up i.e. normal stomach contents, chunky bits or nasty, foul smelling malena? Normal stomach contents

During the time she has been vomiting has she been holding down fluids and if so, can we have a look at her fluid chart (if she has one) Staff says they did'nt know she was vomiting till they just found her and called you

How crook does Nana seem to be? Huh?

OK, leaning forward now

Snoring resps, deep at 20/min

Suction done.