1EMT-P

I don't know how long your Crew Chief has been practicing, but a paper cup with oxygen tubing IS NOT appropriate for a 4 year old pediatric patient in respiratory distress with an oxygen saturation of 89%. The Blow By Technique Does Not provided high concentrations of oxygen and should only be used if a pediatric patient doesn't tolerate either a nasal cannula or a face mask.

I would not treat this patient as a DNR, but instead would start treatment & consult with a Medical Command Physician.

I was interested in her CBC, also if they had done a Sed Rate. Infections & Toxins were at the top of my list.

Does your patient have a medic alert? Do you have any PMHX? Does she have an meds with her? What's her Pulse Ox on room air? I agree with the c-collar, long spine board, IV of NS & Oxygen. I would also like to know about her lung sounds. I would also like to know what her labs were like, including ABG if she had one.

I followed up on this patient 24 hours later. It turns out that the infusion center staff had increased the rate at which her platelets were running. They also double checked everything, the platelets were fine. After arriving at the ER she developed increased hives, itching & swelling of the face & throat. She was given an additional dose of 0.3mg IM Epi, along with 25mg IV Phenergan & 20mg IV Pepcid. Then transfered to a larger facility for further evaluation.

So you are called to an outpatient infusion center for an 18 year old female patient who has a history of allergies, asthma & a rare cancer & has been receiving weekly labs, followed by a scheduled platelet infusion per her MD. The nursing staff tells you that she has been receiving weekly platelet infusions for the past few months & that she has never had a reaction until today. That shortly after starting her infusion she began complaining of hives, itching, swelling of her arms, chest, face & neck. Upon exam you find her lying in bed, her skin color is pale, with noted redness & swelling. She is alert & oriented Her pupils are PERL, there is negative JVD, her trachea is midline, her lung sounds reveal some wheezing, abdomen is soft & not tender. CMS is intact. The nursing staff reports that she has allergies to Benadryl, IV Contrast, Nubain, Ragweed, , Reglan, Sulfa Drug & Vistaril. Her medications include Albuterol, Claritin,Flonase, Lortab, Zofran and an unknown drug trial medication. The infusion center has an IV of NS running at 125 ML/HR & they have placed her on 4 LPM of Oxygen via Nasal Cannula. They have also given her an Albuterol treatment, 20mg of Claritin PO, 125mg of Solumedrol IV, drawn labs & obtained an EKG. Her vital signs are as follows: BP 120/84, Pulse 110-120 Sinus Tach, RR 22, Sats 94% on Room Air. You give the patient 0.3mg of 1:1000 Epinephrine IM & transport her to the ED.

1. How many of you have ever encountered a platelet reaction?

2. Does your agency have a transfusion reaction protocol?

2. Is there anything else that could have been done for this patient?

While I sympathize with families and victims of violent crime. As an EMS provider with twenty plus years of experience I can tell you that I have seen lots of violence over the years and in most cases there was either a behavioral health issue or a substance abuse issue that lead to the violence. So before we go taking away people's civil liberties and civil rights I think we need to look at the real issues including the lack of access to affordable behavioral health and primary care services and a lack of funding for things such as programs for at risk youth, grants to hire more school counselors, grants to hire more police officers in schools, drug abuse and mental health education programs for communities, families and schools and improved disaster education and response programs for communities and schools.

It takes lots of practice locating and placing an EJ, it usually depends on the patients anatomy and positioning. I personally haven't placed one in the field in years so I would attempt to place a traditional IV first, then if that failed I would move on to an IO.

I have used quick clot in the past, it seemed to work fairly well.

Sorry I am so late in responding. I've only seen this condition twice in 20 plus years, but if memory serves me right at my advanced age I believe that the arthritis is secondary to an infection in either the gi or urinary systems.

I agree, while the EZIO is more expensive it appears to be of better quality & easier to use for newer providers!

Based on my years experience, I feel that the EZIO is the way to go. Yes it is more expensive, but it also works very well when you are in an emergency situation without IV access.

I agree with Kate protocols are usually region specific. For example the closer you are in a urban area you might have less interventions & procedures that you can perform, but if your in a remote area you might have more interventions & procedures that you can perform based on your protocols.

How many of you have taken online ACLS or other CE? Any specific site recommendations?

I am not NREMT registered, but if I were you I would do the following: 1. Contact the NREMT to find out about what they require for CE & if online CE is approved 2. Contact the PA Office of EMS & see if any of their CE is NREMT approved. Good Luck

I have seen many trends in EMS over the years and I think the time has come to focus all of our efforts on improving how we educate and train providers using evidence based medicine. The simple fact of the matter is that most providers aren't proficient in skills like intubation because they simply do not get a chance to practice their skills on a regular basis. I think the time has come for us to seriously consider removing intubation from the scope of practice of most EMS providers with the exception of aeromedical and critical care paramedics.

I think the first thing that you need to do is talk to your fellow Paramedics and then to your Medical Director. It sounds like you need to have a protocol for these types of patients. The Medical Director then can talk to your local ED to see what can be done to help with these patients. One possibility would be for the ED to contact local community mental health professionals about being on call to see these patients before discharge.

Normally anytime we started pacing in the field we would call ahead to the ER. The ER staff would have their crash cart in the room with their pacing equipment setup and they would also have some Dopamine hanging and ready to go. We used the same pads, so they would usually turn our pacer off, run a strip and then start pacing with their own equipment if need be.

The highest blood glucose I've ever had/seen was 1500 mg/dl. The patient was in his 30's and was in the hospital for 7 days. He had was sick with the flu and didn't take his medications for three days.

I would recommend that you try laying the patients arm across their chest area while doing their pulse, count for 30 secs for pulse, then another 30 for resps & mutiple x2.

It appears to me to be A-Fib with RVR which can be considered an SVT of sorts. One of the things that they will sometimes do is give a dose of Adenosine to slow things down a bit to help see if there are any P waves.

I have seen low dose Dopamine used in the ICU by both Cardiologist & Intensivist. They usually would start at 2.5 mcg/kg/min. It was helpful especially for people who had bradycardia, lower blood pressure & also decreased urinary output.

To be honest with you I am not sure why we have so many levels of EMS providers in the US. To the best of my knowledge there have never been any studies done that show that "Intermediate" life support or ILS improves patient care or outcomes. Instead of spending money on things like ILS why don't we focus on better educating the EMT's & Paramedics we have.

I would not consider it a failure, it would be normal to start BLS first, then start ALS.

Based on what you have told me so far, I would not consider this patient to be stable. I would consider her to be in serious condition & in need of either a step down or intensive care unit. It sounds like she has developed a post operative infection possibly sepsis. There is also the possibility that she could have PE's. I would be interested in seeing her chest x-ray, Ekg, lab results especially her CBC & Blood Cultures, H&P & vitals.