mobey

Much like chbare, I recently had a cva patient within the window refuse care/transport. Elderly with little family, and ready to die. I sat with him for a while and shot the shit about random stuff and ultimately left him at home. Seems wrong, but eventually everyone has to die. Those who take control of it are truly at peace. I am not interested in disrupting that.

Excellent I chose to use 100mcg of Fentanyl to get her sedated without hypoventilating. She then accepted an NRB. I used the NRB to get her Sp02 to 85%. Then I pushed 20mg Ketamine. At this point the 2 synergized to provide adequate sedation without affecting ventilation or blood pressure, and allowed BVM preoxygenation. It took 3 people to provide adequate BVM with a OPA, and an NPA (which caused epistaxis btw). Once her Sp02 reached 94% I pushed 100mg Ketamine, and 120mg Succ and intubated first pass. OK ..... lets move on..... this aint over Post intubation vitals BP 72/40 Pulse 70 Spo2 90% EtC02 12 Temp 37.6 Air entry sounds= crackles throughout, wheezes in apex's. To recap treatments So far: 7.5 tube, easy ventilation at 36 breath/min. 3lt of fluid in. Dopamine at 10mcg/kg/min. Sedated with Ketamine.

Kiwi, you are very close to my way of thinking... not quite, but close. I agree that RSI is indicated, however let me repaint this picture for you: You have an extremely hypoxic (Spo2 77%, blue, diaphoretic, confused), Obeise patient who is combative. IF you choose to just slam a bunch of meds & RSI this patient, there is a HUGE risk of an inability to bag with a mask to preoxygenate (Think sleep apnea). So the decision becomes: 1) Accept the risk of intubation without preoxygenation and quickly intubate 2) Find a way to preoxygenate her 3) Find a way to oxygenate her without intubating 4) Assume fetal position in corner of ambulance and wait for her to code (ACLS is easy)

Cool guys, great interaction here. I'll move this along.... After 4lt of fluid there is 100ml urine output. BP is unchanged an Dopamine is started and rapidly titrated up to 10mcg/kg/min. MAP is brought up to 60. After about 45min of transport she begins getting confused, tired, diaphoretic, and combative pulling off NRB (she wouldn't tolerate CPAP). Current vitals Sp02 77% (Removed 02, too combative to keep it on) BP: 88/50 Pulse: 70. ECG unchanged You are 30min from closest clinic, 1.25hrs to a hospital. BLS ambulance backup 15min away. Air entry sounds unchanged - crackles throughout

Ahhh, as usual Arctic is on the right train! Safe bet to be weary of pneumo... However if you look at how this has progressed over 3 days, with a crackly chest, CPAP might be safe after all! Hell if we can't oxygenate her, pneumo or not her outcome is dismal. Prior to CPAP that BP should be stabilized. CPAP will result in the loss of the bellows pump of the chest and therefore decrease preload. I know I am preaching to the quire, but others may be reading this thread. No Norepi, but you got Dopamine onboard. 2lt of fluid in, and no change in Bp, and no urine output.

Yes, increased pain with cough. For all questions regarding x-ray - I have given all I was given. Nothing noted on chest exam, except obeisity and pain on palp consistant with the fractured ribs. You take the 02 off long enough to move her to your cot. He Sp02 drops to 82% and she is c/o increased SOB. Accessory muscle use is noted in the abdomen with or without 02. 500ml does nothing for her BP. Now loaded into the ambulance she is back on the simple mask @10lt. Sp02 88%. Pale, diaphoretic. BP 76/42 HR70 Resp unchanged

Yup.... That's the problm with this call, not enough informion to make a good Dx. Deprioritize the Dx and start treating the symptoms.

I would love to share the labs, but you get what I got. Let me quote the nurse. "All the labs & x-ray are online. The Doc is back at the clinic so I can't get them for you" No new labs/x-ray were done today, only the first ones at admit 3 days ago. You could not assess trending. Welcome to my world OK, normal BP? She has been around 130/85 for the last 3 days. Chest sounds= Loud course crackles throughout. Heart sounds unremarkable. Pt sts some pain on deep respiration, but overall only a 3/10. Much better than previous days.

We recently had a medication shortage here in Canada. We were told explicitly "Until further notice, keep all expired medications. If the shortage turns into a crisis we will be administering expired medications to patients" It never came to that point, but the reality is solid. Both the manufactures, and the pharmacists know that expiration dates are a sales gimmick.

You are called for a interfacility transfer from a small health centre for a 60y/o female, it is 10am. 3 days ago she fell down 2 carpeted steps onto her right side. She has 4 fractured ribs. She has been an inpatient since the fall, She walked in on her own. This morning (now day 4) she began deSating and c/o SOB. She has been eating well, and had normal output till today. Current Vitals: BP 78/42. Resps 34. Sp02 92% on simple mask at 10lt. HR70. ECG= Inverted T-waves in V2&3, otherwise normal sinus. GCS15 - pleasant, and totally oriented. Her Foley was emptied last night at 3am, and is still dry. She is pale and quite diaphoretic. She is obeise at 5'5 and 290lbs. Nurse states the chest x-ray shows no pneumo or hemothorax, but "bilateral consolidation" They do not have a paper copy of blood work, but have sent it electronically to the receiving facility. Nurse sts her HGB was a little low, Creatinine a little high, but otherwise normal. Once again I will remind you, these are family medicine doc's and long term care nurses attempting to handle emergency cases, so be weary of thier interpretations! She has had 500ml bolus of NaCl and 10mg Morphine PO for pain. Her only Hx is HTN and arthritis. She takes Propranolol, Pantoloc, and Arthrotec. All of which she took today. You have a 2hr trip to a university affiliated hospital/trauma centre. No air available.

I used Levo a couple weeks ago in Cardiogenic Shock. I have also used it in Sepsis. We don't carry it though, gotta consult OLMC then pick it up somewhere. How about Activated Charcoal?

Along the same lines as Arcticats suggestion, you should write up a formal letter to your medical director to plead your case.

This is pure comedy! Don't be offended though, I have been in the same place as you. One day you will look back and wonder what you were thinking with such an extreme "first aid" bag. This is truly harmless fun though. As ling as you stay in scope, and stay off the hwy, you can't do MUCH harm. I 100% disagree with the statement about organizers making MCI's easier to manage. The only equipment you need on the scene of an MCI is OPA's, handful of boards, a few tourniquets and a radio. If you are running an MCI and end up putting on a nasal cannula and an eyepatch, you have failed.

Let me in on this!! Step 1. Buy a semi truck Step 2. Purchase a flatbed trailer. Step 3. rent a vehicle loading dock. Step 4. Go obtain your truckers licence Step 5. Try to score a contract with an ambulance manufacturer to transport their ambulances to and from their customers in Pennsylvania.

It seems I cannot "enter" and start a new paragraph on this forum since upgrading to Windows 8. The cursor also periodically jumps around the screen. Anyone else have problems?

Mike: I suspect the reason you don't buy this story is because you have no experience in the healthcare scene. It is really a really poor attitude for fresh EMT-B to come into a thread like this where a practitioner is clearly reaching out for advice from fellow healthcare professionals, and get brushed off by an arrogant No0b, presenting yourself as "suspicious". What could the poster possibly gain from this thread other than a little compassion?? They are not asking for legal advise or money! Anyway; on to the OP. I suspect you also may be new(er) to EMS. This is a crappy lesson to learn, but it is a very real one. Sometimes horrible things happen to good people and children. Sometimes the healthcare system fails royally. You need to decide for yourself how far you are willing to go for this one patient. IF you decide to persue this, it could very well cost you your job... or possibly your cert, but most definatly, your reputation will change. If you decide to do nothing, you may not be able to live with yourself. I have no idea! What I do know is that you WILL run into very similar scenario's frequently and if you do not decide right now, how you are going to deal with these unfair instances, you WILL burn out rapidly. You must make peace with yourself.

Doubt it is allergic reaction with this finding

Well it's not an "S" word, but I'm going to take the safe route and treat him like a ruptured AAA. Hold off the fluids, and start Dopamine. I like Ketamine for this guy for pain, and will also use it to intubate if his GCS drops off. Depending on where we are, we better start thinking about air transfer. Was this bloody diarrhea? Oh ya.... don't palpate the abdomen! I would like to know if it is ridged though?

What do you do in the event that you are called to do a transfer of a patient whom is already being paced by your hospital? (Also... anyone know why my "return" key won't work on the city?? Not windows 8 compatable?)

This is one of the best questions I have seen posted here in ages. I always end up trading the ER LP's until we get back, but that is the nice part of working remote EMS, we always return to the same community, and have trust between agancies.

No worries! I also agree that EJ is less invasive, however, in my experience (anecdotal as it may be), EJ on adult patients is quite difficult to secure to the neck tissue and is psycologically hard on the patient. IO on the other hand is simple to secure, and since it is done down on the leg the patient I have found patients tolerate it quite well. In this area, IO is commonplace. EJ is really falling out of favor because IO is so simple, fast, and pretty well foolproof if you landmark correctly. I know this is a comparison with A.C, but I am just pressed for time at the moment. just wanted support that EJ is not one of the simpler IV's to establish...... or keep established. http://www.resuscitationjournal.com/article/S0300-9572(09)00473-0/abstract

In this area EJ is second to IO. IO was refused by the cardiologist unless completely necessary. If IV access was "Needed" I would have went straight to IO.

Thx for the participation guys. Here is what I did No EJ/IO 2xSprays nitro with IO close by. If she dropped her pressure, I would have placed it. Serial 12 leads q 20-30min, with no changes. Enter the cath lab: IV is attempted 8 more times (literally)... all Fail Right femoral - Fail Left fomoral - successful Peripheral vascuilar disease diagnosis charted Heart circulation visualized = 100% LAD occlusion Stent placed, circulation restored. Pt given 50mcg Fentanyl for pain Anterior wall motion absent. EF calculated at 26% Not candidate for ventricular assist device d/t peripheral vascular disease. Pt refuses DNR= Sent home 4 days later Standby for scenario #2

You're from CO? This is your first warning.... J/K Welcome Chris

Nitro is supplied at 0.4mg spray. Oh yes.... the feel/legs/upper arms etc were all tried. 9 times in fact! There is no chance at IV unless you go EJ. I would love to post a 15/18 lead for ya'll, but I just didn't do one. I am not posting a fake scenario so I don't wanna make crap up. So before I wrap this up, are we spraying the nitro without a line?