fiznat

Hahaha not a Hanson brother I don't think. Pretty sure. HX: Asthma, IDDM RX: Albuterol, Novolog All: PCN Prior history: he had an episode like this "a few years ago," but doesn't remember any specific diagnosis. He thinks that the pain started in his hands while he was driving yesterday, and progressed to his legs. He's been feeling weak and tired lately, but has been carrying out his daily functions, walking, etc.... just more slowly. hahahahahahaha GP thats funny. No he did not see (or probably have) a GP. For people of this sort, the ED is usually the acting GP if you know what I mean. doo bei doo wah dooo bop

I don't usually do case studies this way, but I think the result is more interesting if we do a more interactive format this time. I'll give the basics, and (if you want) you guys ask me what you would like to know. We'll end up with the diagnosis (which I have), and hopefully a discussion about it. Dispatched priority 1 for difficulty in breathing and leg pains. On arrival you find a 30 year old male laying supine on the couch in care of first responders and family. The patient seems to be in mild distress has he lays still on the couch. He complains that he has been "feeling like shit" for the past week, including general weakness, malaise, and loss of appetite. About 2 hours before he called 911, the patient had a gradual (over about 30 mins) onset of severe leg pains, starting at the posterior quad area and radiating towards the ankles. He describes the pain as "squeezing" in nature and rates it at a 8 out of 10 (much worse when he moves). Shortness of breath seems to be a very secondary complaint compared to the leg pain. VS: Pt is AOx4 GCS 15 BP: 134/76 HR: 80 RR: 22 Lung sounds clear, skin pink/cool/diaphoretic What would you like to know? (and please dont one person give me a huge list, let's try and get a few people involved)

I think the reason you are getting the "all or nothing" impression is that medicine (and I use that word on purpose) is cumulative. Understanding of physiology, pathophysiology, and treatment must come in that order, and it is VERY difficult to take just one aspect and try to isolate it from the rest. That is why midlevels have had so much trouble, and require such supervision when they are practicing in their field. To administer a treatment requires not only knowledge of the mechanics of that drug, but also the physiology it acts on, the complications that may arise, and the signs+symptoms that make that treatment necessary. You cannot isolate a treatment from the wealth of knowledge that supports it's use. To offer a class on Epinephrine alone, or any other treatment, would require instruction on such a wide array of subjects that I think the class would be prohibitivly long. You can't respect this education, and then break it up into small pieces. It is one of those things where "the whole is greater than the sum of it's parts." As far as administering Epi through syringe vs autoinjector, I dont see a problem with that as long as the administration remains within the same (EMT- scope. Drawing up a drug with a needle is just a mechanical task that can be taught to anybody, and there is no need to assume that EMTs are not capable of doing this. If you sought to expand the situations in which an EMT may decide to administer that medication, though, THEN I would have an issue.

Well there are questions you should be asking your preceptor, and questions you should be answering on your own. If your question is something that deals with medical detail, pathophysiology, pharm, or something like that: you might be better off consulting your textbook or some other trusted academic source. If your question is about handling yourself on scene, the order in which things should get done for various kinds of patients, or how to better get histories from a patient interview, the preceptor is probably the person you should be asking. Keep in mind though, that there are MANY different ways of doing things. Take the advice when you get it, pick up what you like, and prepare to create your own style once you are own your own. There is no clearly defined "right" way to do these kinds of things, only general guidelines that most medics follow. Pick up what gems your preceptor is willing to hand out, nod your head in agreement whenever possible, and understand that the ability to do this well comes with PRACTICE, not instruction.

I don't think it has very much to do with cost. The people who put together our protocols are entirely separate from the people who write the checks to pay for the drugs. Our protocols are designed by regional doctors for use by a large number of separate ambulance companies operating within a specific part of the state. Even still, the protocol only partially dictates what we must by- evidenced by the fact that we don't carry Reglan even though it is in the flowchart above.

Its a freaking powerpoint presentation at a city council meeting, jeez. I made a proposal to my city council in high school about the quality of school lunches. C'omon. I understand grass roots efforts and all of that, but really we should be fighting for a national lobby, not hoping that some teensy spark in a single town backed by a single guy will cause widespread change. All the power to him, though.

We recently got Zofran added to our nausea/vomiting protocol here. I will attach a copy of it below. Zofran seems to be restricted to last-line, only AFTER Phenergan (or Reglan, which my company does not stock) has already been attempted, or if the patient is allergic/reactive to Phenergan. Everything I have heard and everything I read says that Phenergan is a dirty drug with lots of unwanted side effects, potential danger, etc etc. I know that Zofran is often used for prophylaxis against n/v only, but still I think it is pretty common for symptom relief as well. It seems odd to put Zofran all the way at the bottom, only after another (more dangerous?) drug has been tried or contraindicated. I will of course ask our medcon docs when I get a chance, but can anyone offer any insight or idea as to why our protocol is written like this?

Nicely put, Dwayne. Not many of us get the opportunity to be taught something like this in such a clear, effective manner. The fact that you recognized the opportunity for what it was makes it even better.

Nobody has touched on it yet, so I'll go ahead and bite the bullet. I think a lot of medics take offense easily because there is often a bit of a superiority complex. Coupled with the shallow nature of the paramedic education and the wealth of what we do not know, I don't think it is any surprise at all that paramedics are touchy when they get questioned on the "whys" and "hows" by probing students. A lot of medics think that they know everything, and in the EMS world, it is easy to present yourself as such among EMTs with less training. Pointed questions tend to root out the fact that there are still gray areas, though, and I think it is very telling that some paramedics get sore when students start poking around. To me, the "how dare you question me" response seems to illuminate insecurity rather than the opposite. Naturally there is still professional etiquette in the way a question should be asked, but I think my point stands. Now don't get me wrong. I am a paramedic myself, and I have LOTS of respect for MANY paramedics who are incredibly adept at what they do, who are very well (albeit self) educated, and are humble about the things they do not know. These people amaze me. The sad truth of the matter, though, is I don't think these people are of the majority. I don't claim to be an exception, but it is something that I fight against and think about every time I am at work.

Why the LMA though? True it is a little easier to place and it fits a wider population of patients, but it doesn't protect the airway from aspiration at all. What about that aspect? Also understand that we won't be able to fit the whole set of LMAs in the bag. Probably just the big one or maybe the two smaller ones.

My company has had the Combitube for a while now, but recently we have also started stocking LMAs in 3 sizes (not sure of the numbers off hand, I think they are #3, #4, #5? Small, medium, large in any case). Assuming there is only room for ONE of these backup airways in addition to your regular intubation gear in the carry-in bag, which would you choose? Combitube or one of the LMAs? We've got those big red StatPaks that are pretty much already packed to the brim with all kinds of stuff. Assume for the purpose of this thread that there is a set amount of available room and that something else cannot be removed to make enough space to carry both. Naturally we can stock both in the truck, but room for only one in the bag.

Good case study. Atypical presentation and a nice little red herring thrown in the mix. I've learned something. :thumbright: We should have an archive of these somewhere. ...If nothing else other than a stickey that has consolidated links to all of the (many!) quality case studies we've had.

Huh? Morphine helps with a AAA? How is that exactly?

Like Anthony said, it sounds like some sort of perforation/dissection/aneurysm/etc. Without a mechanism of injury, pertinent finding, or history, I imagine it would be tough to determine exactly what vessel is causing the (assumed) bleed. Aorta would top my list. At this point though he is just hypotension with back pain. Could be a bleed, could be pericardial tamponade, could be muscular back pain and some other patholgy combined. Not saying you did anything wrong, but what happened to permissive hypotension? 84/42 is a little low still, but I would have been extremely cautious with overloading this patient with fluid. This assumes we are in fact dealing with a bleed, but new PHTLS suggests that aggressive fluid loading in these patients can accelerate the hemmorage and dilute the remaining intravascular volume. Perfusion with blood made up of 1/2 NaCl is just as bad as hypoperfusion. Two IVs for sure, but perhaps not wide open. So what did it turn out to be?

Okay I met up with a friend in the ED today and got a print-out of the patient's chart. 23 pages, so I will try to summarize: Tx in the ED IV Rocephin IV Zithromax 40 mg Lasix IVP 1 x Combivent Neb 650mg Tylenol PO Labs There is a lab bonanza. I will mark only the abnormal findings. All else normal: WBC - 15.8 (high) RBC - 4.03 (low) MCH - 33.0 (high) PLT - 133 (low) LYMPH - 17.2 (low) NEUTRO - 75.8 (high) POTASSIUM - 5.6 (high) BUN - 41 (high) Creatinine - 1.4 (high) BNP - 1830 (high) Two blood culture studies were done, and both were negative for growth. Radiology A portable chest x-ray was done. Here is the report: Findings: No previous films are available for comparison. Single frontal view of the chest was obtained. The study somewhat limited this patient is rotated. Increased density seen behind the left heart with blunting of left costophrenic angle which suggest pleural effusion and possible associated left lower lobe infiltrate. The remaining lung fields are clear. There is no pneumothorax. A calcified granuloma is seen in the right lower lobe. Findings suggest left pleural effusion and possible left lower lobe infiltrate. Hospital Course The patient was admitted to a floor and kept under observation for 2 days. The final discharge diagnosis was threefold: 1) Pneumonia 2) CHF + Cardiomyopathy 3) Dementia Go figure. Both.

Dispatched priority 1 for the lifeline alert. O/A find 80ish y/o female complaining of "I can't find my remote." TV remote found under pt's pillow. Cleared scene "no medical, community assist only."

I use just regular plain notepads-- I get em in packages of 6 or so for a couple bucks at CVS. Usually this is the limit of what I write down: Unless it is a complex complaint or a large list of answered questions, I am usually able to remember answers to the assessment questions long enough to give a report and write a run form. If I need to write more, I just flip the page over and scribble some more notes.

Wow... Okay, I am on a computer at school right now so I can't get too in-depth, but to answer a few things: The only reason I posted an ABG is because it was the only "lab work" done by the time I left the hospital. I felt it added an interesting component to the presentation as well. As far as values being calculated, I dont know much about ABGs but only one of the values there (SO2) is marked as "calculated." The others, by contrast I assumed are NOT calculated. Also keep in mind that the ABGs were done at the hospital, while the ETCO2 numbers I reported were on-scene and during transport on the LP12. The patient did evolve slightly between these two periods with my NRB O2, NTG, and proper positioning. I will get followup tomorrow, including all of the lab works you guys could possibly desire. The discussion about the utility of a neb treatment for this patient is an interesting one. People seem to be going both ways on it. I was worried about B1 effects with this tachycardic, ischemic, possibly failure patient.... although at the same time she may have benefited from a bit of bronchiodialation. Keep in mind though that a NRB alone brought the SPO2 up to almost 100% as it was. The patient was in fact a DNR, and at the same time probably not a canidate for a tube. GCS 14-15, and we are neither allowed RSI nor sedated intubation. Would you guys really have performed deep tracheal suctioning on this alert patient? I've never seen anyone do that, and also I doubt she would have tolerated it. There was nothing upper airway that I would have been able to reach-- I didnt even think about doing this. I'll return with ED updates as soon as I can get them.

I didn't give lasix because of the potential that this patient was suffering from pneumonia instead of CHF. The skin temperature was the biggest hint towards this, as well as the tachycardia (fast heart beat is typical in patients dealing with infections). Also I was pretty sure I heard rhonchi (mucus, typical of pneumonia) and not rales (fluid typical of CHF) in the lungs. While all of these aren't exactly enough to conclude that the patient definitely has pneumonia, it was enough to make me cautious. Lasix is dangerous when given to pneumonia patients because it runs directly counter to the correct treatment for this condition. Patients with pneumonia are at high risk for sepsis, for which the first line treatment is almost always FLUID. This is because the peripheral vasculature tends to dilate, which drops blood pressure and decreases cardiac return (which also drops blood pressure). Also in these patients there is often a redistribution of fluid inside the body, which can also lead to low blood pressures. All in all, I imagine you can see why taking fluid away from these patients could potentially be a bad thing. In addition, and this is a bit anecdotal, I have been told that rapid diuresis has a tendency to "dry out" pneumonia mucus within the lungs, causing it to be less mobile, more harsh, and effectively more obstructive. Lasix does nothing to change the amount of mucus within the lungs, but there is a potential there for that mucus to become even more dangerous than it was- which is another reason to avoid lasix if possible. I'm sure there are other reasons why lasix is dangerous for these patients. If anyone has more to add, I would like to hear.

Yeah, and this was 3 times that dose! I understand that we all have different protocols and that people do different things all around the world, but I must say that it has been at least my experience that 30mg of Versed is an exceedingly high dose for seizures in the field. Is there anyone here at all who has, as an EMS provider, given this much?

I agree dude. I freaking hate lung sounds. Perhaps it is inexperience, but I constantly fear coming into the ED with a patient I have decided has rhonchi and then have the MD/RNs turn around and say "uh, no. That's big time rales-- how did you not notice that??" The two are hard to tell apart, and despite other associated signs + symptoms (like we see in this case), often the truth is still far from obvious. I suppose this is why tests such as BNP, chest x-rays, labs, etc exist. ...Because the basic signs + symptoms are very often not enough to tell.

Jeez, 30mg of versed?? Thats a freaking LOT of benzo... I donno, we're not allowed to come even close to that kind of dose around here (like medic said, we do 5mg IM only, but prefer IV Ativan). Are you sure you've got your facts straight? I mean I was reading research on sedated intubation the other day and they were using similar versed dosages to obtain basically RSI-ish obtundation, and they were consistently worried about hypotension and all the other nastyness that comes from such high dosages. I suppose it comes in different concentrations, but around here we get Versed in 1mg/mL... Assuming they have the same that means they put 30mL of fluid into a muscle? Jeeeeezz......

Yeah I work tomorrow 1500-2300, I'll try to get follow-up info if I can. It shouldn't alter the discussion that much though. This is still an EMS forum, and most of us are going to be without lab results and chest x-rays when we meet these kinds of patients in the field. I'll get that info anyways though. It should prove interesting.

You guys seem to be pretty sure it was pneumonia, but what about the other findings that point towards CHF? Significant hypertension, a history of the same, acute onset of the symptoms... Those are all pretty strong factors that suggest CHF. I was worried about this call because the factors that I had that pointed towards pneumonia were fairly subjective. The lungs sounded more like rhonchi than rales, but honestly in my limited experience it was borderline. The skin FELT hot to the touch, but she was under a bunch of blankets and we don't carry thermometers. In contrast, the factors pointing towards CHF were objective. High BP, history, etc. Looking back it seems that I made the right choices, but to be honest this was a really tough one. I could have very easily gone the wrong way and really messed this patient up.

I have never seen CPAP used for asthma. Our protocols specify that the patient must be alert, spontaneously breathing, and with bilateral rales. Also, the systolic BP must be over 100 and the patient must have no history of pneumothorax.