mobey

Since you are just learning, it is inappropriate to make statements about ruling out seizure that you made earlier.

This looks like a clear cut Dystonic reaction, and therefore I would "trial" Benadryl I.V.

If that does not do the trick, I would move to Benzodiazepines under the differential diagnosis of partial complex seizure.

Think horses my friend.

Welcome to the forum BTW:

I am sure you know I was not speaking about you Arctic. I can sense the sarcasm in your post

I will agree that tact is not SCoP's strongest areas, however, large bodies such as them paint with wide strokes, and I believe this is one of them.

Although it will cause some practitioners extra work and expence and it is not always fair, this is really just a demotion for the poor job performance crowd.

Leaders work hard and put in the extra effort to stay on top, as far as I am concerned the rest can be left in the dust on this one.

I base my opinion on multiple experiences. If you look west into other health districts I do believe you will find stations filled with these EMT's who cannot be bothered with competence. If you do not know it is a major problem, then that simply represents you are not exposed to it, not that it does not exist.

To answer your question about what I did: I reported it, the 2 practitioners were put on temporary suspension while it was investigated, They were so offended they quit. 4 weeks later the health region shut dwn thier service due to staff unavailability and all thier calls came to our station 1/2 hr away.

That was the last time I reported anyone in Sk. Just too fragile of a system. We are better off trying to teach from the inside.

I think it's very unfair that they would demote or "freeze" any providers licence level because of ScoP's lack of foresight and lack of transparency.

I disagree.

I think they are demoting those hillbillies who are still harming and refusing to treat patients based on their 1976 2 week EMT course, and 30 years of repeating the same "scoop and scoot" bullshit transport on every patient.

There are some very very poor practitioners in rural Sk (and Ab) and I think this is a great step towards a "S**t or get off the pot" motivation pushing them back into the classroom to increase competency, or off the ambulance.

Until you do a ALS intercept to a unconcious preggo with a C-collar upside down, and a NRB at 4lt, you may not understand

If you`re working EMS or have specific knowledge that would apply to that situation (proven by a degree or vocational training), you do have the duty to render more care than an untrained bypasser, as an EMS worker.

I don't buy this as fact.

How is a degreed paramedic supposed to render anymore care than a lay-person when he pulls over in his POV wearing shorts and a t-shirt?

No PPE, No equipment = No help from me!

Truely sorry Idon't have time to offer advice.

But start here:

http://www.emtcity.com/topic/21642-longevity-in-ems/

For the first time, I am going to disagree with chbare, and accept my disapline for doing so.

I have a real problem allowing people to decompensate in a prehospital setting. We have potentially the most Uncontrolled intubation setting there is in healthcare, and allowing patients to get severely hypercarbic/hypoxic prior to sedating and possibly paralyzing them, really stacks the odds against us.

Perhaps in a constrictive event, or an edema event, where pressure support can make a dramatic difference CPAP would be first line, but in a case like this, early intubation is my first bet. These and traumatic chest injury patients are just not the ones to deploy the CPAP trials, or wait and see treatment regimes.

Ok. Chbare, let me have it!

I'm with you Rock.

As a sidenote, in Sask, when I used to KED someone they did not get boarded.

Just put on the KED and lay them on the cot.

As a third note... I have used a KED with no board for people who cannot tolerate lying down in this province (Ab), and have never been drug over the coals. Perhaps we just need a few more cowboys to break the mold and make the medical directors ask questions?

Thanks for the case! I'm a bit late, but curious. You mentioned in the initial post that the ECG showed sinus tach with a narrow QRS and no T or ST changes. Not that it is something we're normally looking for, but was there any PR segment depression?

Interesting question. Although I do not make a habit of measuring PR, there was nothing that jumped out at me.

Why would you wait for this woman to code before you drain the fluid? You can prevent that from happening if you drain it now (though I realize you had to do what your standing orders/medical control says). This is a case where prehospital ultrasound would be great. I will admit that given the scenario, I'd be hesitant to needle her without some confirmation that she indeed has tamponade.

As has been said, I don't imagine I would have gotten orders to do it while she was still alive on a risk/benefit basis. Of course I would prefer to do it as soon as I decide I can't maintain a BP anymore, but I doubt any Med Director is going to give the order. This is one of those cases that you hope for no cell service, so you can excersise the "do what's in the patients best interest" communication failure clause

Excellent case - thanks for posting....

Question - Is the pressure/pain radiating to lower back typical of tamponade? in women?

Great question! No idea....

I was a pericardial efusion, leading to tamponade (Obstructive shock).

No, I didn't needle it, though if I could not have gotten her a plane, I definatly would have called for standing orders in case of an arrest.

MAP is calculated by the LP15. Not the most scientific, but better than BP alone IMHO.

100mcg Fentanyl is a little much, I was giving her 25mcg increments, which took the edge off.

So... anyone want to run Dopamine?

Or should we run fluids?

I am not even going to worry about pain/anxiety at this point vis a vis medications. I think we are dealing with a major bleed at this point - I would guess a dissecting aorta. Get that rotor on it's way and get that patient to definitive care. The MAP is not ideal and it is symptomatic with confusion. Hi-Flow O2, hoping that will clear the confusion without jacking up the BP and aggravating the bleed.

Don't hate me

But how do you account for the JVD?

Hello,

Are S1 and S2 normal?

Muffled heart sounds?

New mummur?

Stomach soft?

Maybe, she repture a cardica valve or repture a cardiac aneurysm?

However, I am leaning towrda a repture AAA or a thoracic aneurysm with the sudden onset, lower back pain, and frank hypotension.

I would drop in 1L bolus and start to package her for transport. maybe with a better pressure her LOC will imporove. I would also get ready for a tube if need be.

Stomach is soft.

As I replied to Doc, I don't know enough about heart sounds to give any feedback.

1lt fluid in

BP 82/58 MAP62

HR 112

RR 22

Granted that the MAP has much to be desired, however, I would still be wary about fluid administration. OP stated we have radials…I would be content with this for the time being. Maybe start off with legs elevated as long as it’s tolerated and some 02 via mask if not already done.

Anything we can do for the pain/anxiety? Opioids would be out due to the poor perfusion…anything else at your disposal?

Don't forget a MAP <65 (some will argue 60 but we are not using invasive technology here) means end organs are not being perfused. To withold BP treatment from this patient, is nearly a death sentence.

Pain/anxiety, you can have whatever you want.

I wear two pairs.

5.11 Tactical Sleet

&

5.11 tactical XPRT

Both are awesome, the XPRTs are absolutly amazing!!!

2 pairs of boots at one time?

Hardcore

I'd be initating a prompt transport, IV access but no fluid...

Maybe in the urban setting, but here in scenarioland (and my world) we have a 30min rendezvous with a fixed wing airplane, or 3.5hr by ground.

I.V is in, bilat.

BP 82/58 MAP 54

Resps 22

HR 114

Confused but alert. Still 10/10 pain

No trauma.

As stated, this patient was just sitting there drinking tea.

Sudden onset.

This dude needs a CT and an orthopod.

Great suggestion here Doc

Reflecting on this call, I probably could have gotten orders to bypass the local clinic direct to trauma centre query spinal fracture with neuro deficit.

Some might say the films shot were unnessasary radiation as CT is mandatory in these patients.

As a patient advocate, I could have spared him 4-5 shots of x-ray by bypassing.

Dwayne: I also need to read up on CCS, so I can't help.

Hope to see ya over at last nights patient

Thx all.

Forgot a medication: MTX, and arthrotec.

Sorry bout that....

Maybe thoracic aneurysm/disection?

Bilateral radials present?

Bilateral radials are present. Note I said BP was bilateral

With the + JVD and hypotension, I'm thinking cardiac tamponade, but I don't know if it could occur suddenly like that

OK.... so now what?

Heart and lung sounds?

Lung sounds were clear in apicies, couldn't hear much in the bases.

Her Kyphosis is pretty severe, and chest wall movement is an issue.

As far as heart sounds go: I'd love to say no gallop, good S1S2, but I'd be faking it. I have no idea what to listen for....

I thought her heart sounded quiet... or distant.

Did you do a 12 lead? Any improvement with position change? and palpable masses in the abdomen? Very odd indeed...

See original post for 12 lead.

No, and no for the rest of your question.

Here is an example of the degree of kyphosis

http://www.sciencephoto.com/media/260141/enlarge

My first guess is cardiogenic shock. Any cardiac history?

Nope, no cardiac hx

Well, just when I think I am getting good I get presented with this:

I am sure many of you will have no problem, but it as my first one, so it took like 10min beore I knew wtf I was working with.....

81 y/o female. aprox 140lbs, sudden onset chest pain while sitting drinkng tea with husband.

Pain = 10/10, crushing, radiating to lower back.

Nausea 10/10.... dry heaving like crazy

Pale-grey, diphoreic, good turgor.

No distal edema, JVD present. Complains of SOB

Pulse 112

BP 74/58 Bilateral.

Sp02 98%

Afebrile

ECG = unremarkable. Sinus tach, narrow QRS, no T,ST changes

History: Spondylitis (Kyphosis noted).

Hey guys, sorry for the delay.

I am quite curious as to what ERDoc's take on the x-ray is.

Good call Dave, as usual.

The sending GP stated the following= Central cord syndrome with possible C3 dorsal spinous process fracture (looks like the tip of a thumb broke off on the back portion of the vertebra)

Upper extremity weakness was confirmed after analgesia.

I have no further information, as he was transfered to a tertiary care centre.

Central Cord Syndrome:

• 
  Symptoms of central cord syndrome occur following trauma (most commonly falls) and consist of upper and lower extremity weakness, with varying degrees of sensory loss. Pain and temperature sensations, as well as the sensation of light touch and of position sense, may be impaired below the level of injury.
  
• 
  
  Physical findings related to central cord syndrome are limited to the neurologic system and consist of upper motor neuron weakness in the upper and lower extremities. This impairment can be described as follows:
  
  • 
    Impairment in the upper extremities is usually greater than in the lower extremities and is especially prevalent in the muscles of the hand.
    
  • 
    Sensory loss is variable, although sacral sensation is usually present. Anal wink, anal sphincter tone, and Babinski reflexes should be tested.
    
  • 
    Muscle stretch reflexes may initially be absent but will eventually return along with variable degrees of spasticity in affected muscles.
    

  Surgery is rarely indicated because of the inherently favorable prognosis for patients with central cord syndrome.

  http://emedicine.medscape.com/article/321907-overview

Don't forget to cost in a Medical Director salary, and a lawyer.

Gotta go for a few days, so i'll leave you with this:

Yeah, that Fifty Shades of Grey will get ya every time. Hope you don;t like sleeping at night if your female companion gets hold of the books.

My wife just started reading the first book. She is away right now, but we will be seeing eachother this weekend.

I'll be honest: After 10 years of marriage, I have gotten laid more in the last 2 days over text messaging, than I have in the last 3 years in the bedroom!!

I have conflicting tretments here. Backboard or not?

How do we take this guy from the position he is in, and get him on a backboard?

Bilat extremity pain, not likely to be a stroke. Think of the anatomy that has to be involved. Zactly

A 28y/o with MI/stents, yikes!!! He gets a 12 lead. Time for a lifestyle change by chance?? 12 lead normal

Can he describe this "scuffle" a little more? He states him and his slender short friend got in an argument. He slapped his friend across the face, and the little prick put both his fists together, lacing his fingers into one giant fist and delivered an upracut. It stunned him, and made him step back a few paces, but he did not fall. That was the end of the fight.

Any neck pain/tenderness? No, only pain in the arms/hads

Any incontinence? No

Does he have any weakness in the arms/hands (if he won't let you touch them, will he move them)? He has weakness in his fingers, in fact, now that he is asked to move them, he notices his pinky and ring fingers are paralized.

Where is the rum from, purchased from a store or a home brew? Local store, run of the mill brand.

So when he was rolling around on the grass was there any pesticides sprayed befor that.

It is a gravel lot.

Rolling around?

No chemicals noted