fiznat

I will let the images do most of the talking. This is a 65 y/o male found pulseless + aepnic in an office building. He was a witnessed arrest with immediate bystander CPR. Unknown Hx/Rx/etc. This is actually the 3rd shock (1st shock as noted on the paper, but we had switched monitors), but to abbreviate: link to a bigger version (1500 pixels wide) of the 12 lead here. here is the URL to the big version-- try copy+paste into a new browser, EMT city frames resize the image for me: http://i62.photobucket.com/albums/h99/fiznat/12leadBig.jpg Never got a chance to do epineprhine. The patient got 1mg Atropine for the brady rhythm, followed by a 100mg Lidocane bolus and then a 2mg/min Lidocane drip*. He began to buck the tube enroute the hospital and was given 4mg Versed. He was taken to the cath lab immediately based on our 12 lead and found to have a complete occlusion of the RCA. Stented and sent to the ICU, where he was cooled according to the new ROSC hypothermia protocol. 6 days later, he walked out of the ICU under his own power without any neuro deficits. My first code as a licenced paramedic. 8) **Now I know some of you are going to mention this, so I'd like to talk about it. It appears from the 12 lead that the patient is in a 3rd degree AV block. I did not see this at all during the call. To be honest, I gave it pretty much a cursory look considering all else that was going on- noticing the inferior MI and moving on. The lidocane drip happily dripped away the whole time. What do you guys think of that?

Who is talking about blindly implementing protocols? Uh, I guess you're right we shouldnt do that-- but pick on me, not the straw man. My point was that we often cannot tell how an individual will react to a certain drug. Yes, we generally know how NTG works and what effects (IN GENERAL) it has in the body, however as you and I and every medic here has probably seen: NTG will tank one person's pressure while another will hardly drop at all. It is also true that SOME patients will have obvious indicators of potentially strong reactions to the drug: preload dependent people, for example. Still, there remains the point that there is no way we will ever be able to determine on every patient how strongly they will react to a 0.4mg spray or tab. I have personally found that very few patients know their ejection fraction by heart. To think that you can reliably predict adverse reactions is just silly, which was my point. Fact of the matter is we have to always prepare for the worst, most dangerous reaction, and understand the potential pitfalls. Get a good history, start a line first, be very aware of changes after giving the drug, etc. This goes to the point of my original question. ...Which was about ASA, by the way. Knowing about potential pitfalls and a "prepare for the worst" mentality seems to contradict giving any kind of med simply "on a hunch." In general, though, ASA is much more benign with much less potential danger than NTG. ...Does this mean we can be a little more liberal with its use, and lower our necessary index of suspicion for it's administration? If so, how much? That's the question.

...And yet I have seen patients having MI's with exactly those complaints alone. It is true that we have a lot of diagnostic equipment. Couple that with a solid understanding of cardiac presentations, atypical presentations, equilivents, and experience: I think it is safe to say that a good number of patients we will be able to make a pretty surefooted decision as to whether a cardiac problem exists or not. These are not the kinds of patients I am asking about. I dont think it is fair to say that we should always be able to make a firm decision as to whether an event is cardiac or not. Even with an awesome assessment and the best resources possible (neither of which are always present for one reason or another), STILL there are patients who defy the rules and evade direct diagnosis. If you beleive you dont have these patients ever because your assessment is that good, I'd sure like to learn a few things from you. These are the ones I'm asking about. The "maybe" cardiacs. Where is your level of suspicion for administering ASA? ...And to the guy who said he bases his NTG decision on " a thorough understanding of the effects it will have on that individual's unique heart and vasculature system," I would ask: how the heck does he obtain that information? PMH can only do so much. ...To presume you can predict in an ambulance individual reactions to these kinds of medicines is borderline hubris imo.

I've had a lot of patients like this during my preceptorship, just wondering what your take is on it. Imagine a patient who is presenting in an only vaguely cardiac manner. Something like weakness without ST changes in a female. Syncope in a patient with cardiac history but no other complaints. N/V and diaphoresis coupled with a clean 12 lead in a 65 year old smoker with a history of HTN and high lipids. We see these patients all the time (or at least I do). Basically they will present with one or two of the typical "cardiac equivalents," but will defy clear-cut cardiac diagnosis by denying chest pain/SOB/etc and presenting with clean or unreliable (BBB, pacers, etc) EKGs. How often will you give ASA? My preceptor has often suggested that even if I am not convinced that a patient is "cardiac enough" to give NTG, I can still (most times) go ahead with ASA as the drug is fairly benign (save a few circumstances). It is a sort-of "cover your bases, just in case" kind of philosophy. Personally, the idea kind of rubs me the wrong way. I feel it smacks of sloppy medicine, and it shouldnt be advisable to give medications for conditions we dont clearly see. I'm not sure that it is our place in the ambulance to ever give meds "just in case." On the other hand, though, I understand of course that we have limited resources to evaluate these patients, and often - especially in ACS - time is of the essence. Perhaps it makes sense to give ASA to these patients simply because the potential benefits may outweigh the risks. What do you guys do in these situations?

This may seem like a silly thing, but I am always afraid of losing the narcotic keys. We are required to keep the narcs behind 2 locked doors, and to carry the keys on our person at all times. The keys at my company have these little clips on them that people usually attach to their belt, but I've already had the thing come unclipped once and nearly lost one of the keys. Just wondering what you guys use to carry your narcotic keys (if you even have a system like this at all). I was thinking about getting some sort of locking carabiner setup or something, but havnt been able to find a locking version that is of usable size.

LOL true true! haha

Hey no big deal. I misunderstood your tone as well.

haha thanks guys! To answer a few questions: Yeah we do carry a lot of lasix. Our standing orders for pulm edema are dependent on whether the patient has taken their perscribed lasix for the day or not. If they have, we give them their normal dose (or usually 40mg if they're not perscribed it). If they have taken their normal dose, we give twice that dose-- up to 200mg. The jets for the epi are in a pouch that is between the two sections that I took pictures of. Sorta like a flap that sandwhiches in there. I didnt take a shot of it though cause it's not really that interesting, just a clear case with the plastic jets, nitro paste, few other things. The big jets that are next to the D50 are for the D50 and bicarb only... they're much bigger than the ones needed for the epi, atropine, and lido. We dont carry pedi concentrations for any of our drugs, so if the need arises (and it very rarely does), we'll just mix it up in the buritrol (sp?). "Precepting" around here describes a mini-internship that is run through our medical control and employer. Basically, I have completed both class and national reg, I have a state licence and I passed the written protocol exam. I need to do 30 or so calls with a preceptor/experienced paramedic/mentor (or more depending on the type/quality of call) as a 3rd rider on my company's ambulance before I am cleared to work as a "cut-loose" paramedic on my own. Yeah the thomas packs arent my favorite. It seems most people around here use them though, despite the fact that they often fall apart and the elastic things get worn down allowing all of the vials to slip. We've got new StatPak bags at our company though, so hopefully we'll be getting those drug modules soon as well.

Yeaah I know they're not really "macro" shots technically. They are semi-close-up, or whatever you might call them. (although maybe the Narcan one could be considered macro?) I was using my trusty digital camera, the 3.1mp Cannon Powershot G1 with the regular lens and ambient light only. Nice, reliable camera with manual settings that I've had since 2002 or so haha. It works though, even though its a huge brick and looks like something Marty McFly might use.

Call me a dork if you must, but I enjoy messing around with photography from time to time, and with all the free time I've got in the back of the ambulance while I'm precepting this seemed like the natrual thing to do. Note that these are not all of the drugs we carry. Not pictured are the benzos, narcs, promethazine, ampule 1:1000 epi, glucagon, cardizem, nebs, or NTG paste. There is tetricane elsewhere too. If you spot any expired ones be sure to let me know! :wink: Enjoy!

Yikes. Does this procedure have a technical name? I'd like to do some reading on it.

Chill out, sladey. I didnt say "jam" the bougie down there at all. I imagine the extent of the trauma depends directly on the technique of the provider. The bougie is a soft, pliable gummy tube. I dont think it would cause that much trauma if handled properly. I have no idea what percentage will hit the cords, although I do know that "intubating LMAs" are specifically marketed to healthcare providers. I'm sure they did research, and while I dont very much care to hunt it down because my service does not use this tool, I'm sure it is available if you wish to find out more about the science behind this procedure. I do have some faith, though, that specifically marketed intubating LMAs are able to do what they claim at least a significant porportion of the time. They are widely used. No I have never tried this on a real person. My service does not supply LMAs at all, nevermind the intubating ones. Besides, even if I had, what value would my individual ancedotal information on this subject carry? Other people have used this and found success with it. If this is the kind of evidence you want, feel free to search them out. I know that the cuff does not occlude the esophagus, I didnt say that it did. ...Only that it does do it's part to help direct a bougie towards the correct general direction. I googled the subject and the very first link lead me towards some research: 1. Brain AIJ, Verghese C, Addy EV, Kapila A. "The Intubating Laryngeal Mask-I. Development of a New Device for Intubating the Trachea." Brit J Anaesth 79:699, 1997. 2. Baskett PJF, Parr MJA, Nolan JP.. "The Intubating Laryngeal Mask. Results of a Multicentre Trial with Experience of 500 Cases." Anaesthesia 53:1174, 1998. 3. Dhar P, Osborn I, Brimacombe J, et al. "Blind Orotracheal Intubation with the Intubating Laryngeal Mask vs. Fiberoptic Guided Orotracheal Intubation with the Ovassapian Airway. A Pilot Study of Awake Patients." Anesth Intensive Care 29:252, 2001. I dont know the results of the studies, but this should help you find some scientific basis for your obvious skeptcism of this procedure.

You are supposed to pass the bougie down as far as you can. In theory they say you should hit the carina and meet resistance. You also might be able to feel the bumpy tracheal rings. If it is in the esophagus you would be able to pass the entire bougie (depending on the size of the pt of course) without feeling resistance. Intubating LMAs kind of maximize your chances for blind insertion into the trachea through positioning near the area, and partial covering of the esophagus by the inflated cuff. Youre right, it's not perfect, but I've done it on a dummy a few times and works pretty well. (I wonder if a stiff, hollow tube might be more useful here. ...Something through wich a small amount of ventilation could be passed and then ETCO2 measured afterwards to approximate placement.)

Really, really tough call. Asthma codes are one of the absolute worst-- I'm sorry you had to go through it. I'm not understanding the bit prohibiting you from using the epinephrine, though. I know that there was probably reduced circulation to the peripheral, but certanly not enough reduction to contraindicate a med! You were still reading on the puse-ox... low, but there was a reading. With a patient this bad I feel like I would have tried the epi anyways. With so little air exchange the nebs arent really going to help so you've gotta do what you can... Sedation/RSI would probably have been indicated here as well, but like others have said, mucus buildup would have made it tough to ventilate regardless of how much the patient was fighting. It might have helped you get that IV sooner, though. Also possibly racemic or ET epi? Just my opinion though. Thats a tough call and it sounds like you did as well as you possibly could with it.

hahaha. Sorry ma'am, we cant go to that hospital. The bees have taken it over. Seriously!

Splitting hairs. C'omon, you know what I meant! haha although acccctually I have seen people vagal out of SVTs on the IV insertion alone! So hah! :wink:

I think this question can probably be answered even without the example patient. An unstable (or potentially unstable) patient should get the IV first. Otherwise, it probably wouldnt matter which comes first. The IV is a treatment, the 12 lead is a diagnostic. No ED in the world is going to take your side if you come in with a patient who coded and lost all his access and then say "...but I got this great EKG!" If your patient needs the IV, give it to him. Otherwise- do whatever is easiest to do first.

He was complaining of the headache though... he said it went away after the nose started bleeding. Headache only lasted for a few mins and never came back, all prior to our arrival. Is this typical of SAH?

Yeah probably more of hypertensive "urgency" since there is no end organ dysfunction. Good point. With a pressure that high though I imagine damage isnt far around the corner though... We dont carry beta blockers and have no protocol for HTN. The patient got IV lopressor almost immedately in the ED. It might also help to know that I was working BLS for this call. Still waiting to precept

I shelled out $800 for my EMT-B class. Took it at Boston University and got credit for it so I assume that is why it was so expensive. Medic class was about $4000 for the full year at an accredited community college including books and all certs (ACLS, PALS, PHTLS). Didnt include Nat'l Reg fees.

I'll give you guys a quick run-down of the patient: 54 y/o male was cooking food 15 mins prior to EMS arrival when he had a sudden onset of 10-10 headache pain, "pressing" in nature and radiating to the ears. Almost immediately afterwards the patient's nose began to bleed profusely. Headache went away but nose continued to bleed. The patient currently denies any pain or SOB. Lung sounds/upper airway is clear. AOx4, PEARRL. C. Stroke Scale is zero. No distal edema, no JVD. Skin warm/pink/dry. Pt denies n/v, dizzy, headache, lightheadedness, synope, blurry vision, etc. Pt says this is the first time this has ever happened to him. He says he is compliant with his meds. Significant dark red blood with clots from the nose and mouth. HX: HTN only RX: HCTZ, some unknown "blood pressure" med from W. Africa in an unmarked bottle, ASA ALL: NKDA Vitals: BP 280/160 HR 120 RR 22 I understand about "treating the patient not the numbers," but this is a pretty high BP. The patient is basically without complaint besides the bleeding. Airway is easily managed with positioning and occasional suction. Bleeding does slow with pressure + cold compress. We were about 10 mins from the closest ED. I would like to hear what you guys would think about transport priority. The patient is more or less stable, but I worry that a blood pressure that high can have adverse neuro or cardiovascular complications. It is unknown how long he has been this high but the episode sounds to be fairly acute. I also understand that you are not "seeing the patient," but what do you guys think?

Yup yup, we all believe in the power of evidence based medicine and flexible, assessment-driven intervention but even so: The nurse got a systolic of 100, gave THREE nitros and THEN checked the pressure? :shock: Hopefully you got the details wrong on that bit. People react differently to NTG but I think most would agree that we should be a bit more careful than simply dumping that much drug on this patient without reassessment.

Thats interesting that some people actually get weekenend differential on top of the other Baylor benefits (working only 24 and getting paid 40, etc). I cant imagine our company would ever go for that. I've done some research on the net, found a few Baylor plan models from some nursing programs, and some of them go as far as to not offer ANY premium pay at all. ...Meaning Baylor employees get no differentials, no holiday pay, none of that. As far as why people would want to work these shifts vs. using part-time/overtime to work weekends, this makes sense for a lot of people at our company- including myself. Working only weekends makes it MUCH easier to fill a school schedule (which is what I am interested in). Also for some people this kind of schedule would allow them to work another job, or fulfill child-care needs. Getting a full week's pay out of only 2 days of work is a pretty sweet deal, as long as you dont get screwed on your other benefits at the same time. Anyone else?

Some people at work have suggested that our company start offering Baylor/Weekend-Only option scheduling. For those who dont know what that is, in general this means that employees are scheduled for 24 or 32 hours over the weekend (usually 2 12s or 2 16s on Saturday and Sunday), and paid 40 hours of straight pay. The idea is to attract employees to often hard-to-fill weekend hours by offering a premium pay schedule and reduced workdays. This is fairly common in nursing. Talking about it around the company, the idea sounds pretty interesting. I would like to hear if anyone here is currently working this kind of schedule (or working for a company that offers it). How do you like the schedule? What kind of hours are you working? How are overtime and PTO hours calculated? Thanks guys!

Woah woah wait a minute! Now I am willing to admit that - as a new medic - I may be wrong here, but my understanding is that: Q wave- first DOWNWARD wave of the QRS complex R wave - UPWARD wave following the Q and before the S S wave - DOWNWARD wave following the R That is, a Q is always a negative deflection, an R is always a positive deflection, and a S is always a negative deflection. To be sure, I confirmed this with my handy-dandy Dr. Dubin book and it is so. A quote from the book: Sometimes (like in V1) the R wave isnt very visible. That doesnt make the large downward deflection an R. Sometimes there arent any R waves visible at all, and the first major deflection in the "QRS" complex is negative. Consider this EKG: This EKG has a number of things going on (LAD/LVH, LAH, huge PR), but check out the QRSs in v2 for example. No R wave. We wouldnt call this (downward) wave an R wave simply because it is large-- it is a QS wave. ...Named that way because it is indistinguishable as a Q or S as the definition of those two are dependent on a visible R wave. The R is always up, the Q and S are always down, regardless of which lead youre looking at. By definition, it is the R wave. Its small because of the angle you are looking from, but it is still the R.