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Was he supposed to take his finals today?!!!

Like Ridryder said, there's arses in every job. I'd say though that there are way more arses on ambulances and fire trucks than in the ER. My best story about bad nurses would be the time we responded to a diabetic stopped along the roadway. While we were doing our thing, this car pulls up and a woman gets ought. She's wearing scrubs, and she identifies herself as a nursing student. She then proceeds to tell us what to do. My partner and I were looking at each other, like "What the @^@$#^!?"

My best guess is that she her feeling of being short of breath is not due to any respiratory problem but that that it's cardiovascular. Imagine running round the block as fast as you can. You'd get to the point where you'd feel like you couldn't catch your breath anymore. But in fact it's not your lungs that can't keep up but your heart. We can assume that this lady has CHF considering that she's had 5 MI's, so she probably has very little cardiac reserve. Her heart can't keep up with even a little exertion. She'd feel short of breath and panicked, and that would explain her respiratory rate. This is obviously a very sick lady, and you'd have to wonder if perhaps she had yet another MI. You certainly did the right thing by taking her to the ER quickly.

About 9 months ago we had this teenager who knocked down a tree and two lightposts at 4 in the morning. The damage to his truck was huge, and he was lucky to have not been killed outright. We were first on, and he was slightly confused (4/6/4) but following commands. His only complaint was that he was having trouble breathing. He was anxious and moving around quite a bit (moving his arms and upper body), and we told him to relax. During the extrication, another medic happened to notice that he had a major deformity to his spine. When we got him out, we told him to wiggle his toes but he could not. He was only 19 but will be paralyzed for the rest of his life. No other injuries. I was suprised that he never once complained about not being able to move his legs.

Well, in that case, I would immediately do an emergency c-section. No, no, just kidding. Just work up the code like any other. Consider the hypertension, edema, and her symptoms, obviously we'd be thinking that she is eclamptic.

Good scenario, but I don't have much to add here. If I had this guy in the field and he didn't respond to Narcan and had a normal blood glucose, I would think that he most likely had a CVA, probably a bleed. Of course I would also try to investigate what it was that he could've drunk off the cart. My treatment would just be standard ABC's. I don't have RSI where I work, so I couldn't intubate if he still had a gag.

I've actually laid eyes on the elusive DustDevil when he and Vivi came to Los Angeles for a visit. For those of you that have never met him in person, he stands a towering 6'10'' and has a long white beard.

Some of the best stories I've heard from where I work.... A crew picks up a frequent flyer homeless patient who is slightly altered and having difficulty breathing. They've had this guy before and know he has asthma, so they give him a breathing Tx. They assume he's altered cause he's drunk again. They transport to the local hospital. Hours later the staff at this hospital realizes the patient has suffered major trauma. It turns out he was hit by a vehicle. He is transferred to the trauma center but dies there. The medic lost his job. Another story...a guy get's kicked out of a gay bar. The patient may or may not have been altered (depending on who you believe). The medic puts the patient in the back with his EMT and takes him to the ER. They tell the staff that he's just drunk. He's put on a hall bed and not well monitored. Much later they find him to be unresponsive with a very low blood sugar. It turns out the patient is related to one of the ER nurses, who raises hell. Lawsuits follow. The medic claims that the patient wasn't altered when he saw him, just drunk. He says that it's the hospital's fault for not watching the patient, and that his blood sugar dropped while he was left there. However, the EMT had written on his paperwork that the patient had a GCS of 4/6/4. The medic lost his job.

Yeah, I totally agree that "EMS based fire suppression" is an accurate way to describe fire departments, at least here in So Cal. I just don't think they would ever say it like that since no matter how many medical calls they run, they will always think of themselves as a fire department and as firefighters, with EMS being secondary.

Has anyone yet a "Chicken Soup for Cops" yet?

JPINVIV wrote: "EMS based fire suppression"

Did the medic have the patient on the monitor (3-lead)? He may have had the patient on the monitor, seen that he was in a paced rhythm, and decided that a 12-lead would not be of much value. You would not be able to diagnose ST changes or BBB's if the pacemaker is firing the ventricles.

Dude, your preceptor is an idiot. She really scares me.

I've never understood why the baroreceptor reflex only slows the heart rate. You'd think that in order to lower the BP, it would both lower the HR and also vasodilate.

I understand that the baroreceptor reflex is responsible for the bradycardia in Cushing's, but can the bradycardia also be due to compression of the vagal nerve when the brain herniates, esp. with profound bradycardia?

Coming in late on this one too....Wow, that is an ugly ECG. Wide complex, nasty T-waves...Like everyone else, my first thought is hyperkalemia. Does she normally have an irregular pulse? How does she describe the funny feeling in her chest? Is she still oriented? Since she's now feeling worse, let's lay her down, bump up the oxygen, and give more fluid challenges (paying close attention to lung sounds), and will seriously consider dopamine. Of course we are enroute to the ER, preferably a cardiac care center. Sodium bicarb sounds like a good idea too, but I would consult with a physician before I did that. Someone mentioned albuterol. I understand that this is a treatment for hyperkalemia and that it shifts K+ into the cells, however I'm not well educated on everything that's involved with that use. (Our transport times are usually 5-10 minutes, and we don't have any protocols for treating hyperkalemia except in a full arrest.)

ER Doc wrote, "You note that his blood looks brown in color." Sounds like Vent Medic got it with his idea about methemoglobinemia.

Coming late to the game...and I'm stumped. Since he has no history of lung diseases or any other medical history, and since he doesn't seem to have any problem with ventilation, my best guess is that he's having a PE. Obviously that would be very unlikely for a healthy 16 y/o, even with his recent history of minor surgery. And I would expect to see other signs/symptoms.

Yes, it's AF + WPW. So....does this make any difference in our decision wether to go for an IV first and push drugs or to go right to cardioversion? I'm thinking that you would go straight to cardioversion because from what I understand WPW is likely to quickly deteriorate into VF. Dust, I'd like to hear your opinion on this especially. Also, have you treated patients with WPW before? I've never had one. How well do they respond to adenosine and amiodarone?

I'm really impressed by all the responses so far. Kudos also to the poster who said to put the patient in shock position. I put that in there to trick you guys, and I thought it would be like 50 posts before anyone caught it, but you've proven me wrong! When this scenario was posted on FlightWeb, there was a lot of discussion about if this patient was stable and if he required immediate electrical theraphy. What do you guys think? Someone has already figured out exactly what's going on here (no suprise), but is graciously keeping the answer quiet. I won't reveal anything for a while so that other people will get a chance to give their opinions.

This call was run by an a helicopter crew and was posted on FlightWeb. Thanks to Mike McKinnon for letting me steal it. You are called out for an “unknown medical.” A fire medic is already there, and the first thing that happens when you walk through the door is that he hands you this EKG: http://img102.imageshack.us/img102/3325/ekg28wm.jpg :shock: :shock: :shock: :shock: The 50 y/o patient is sitting in a chair. He’s pale, cool, diaphoretic. He’s already on an oxygen mask. His chief complaint is feeling dizzy when he stands and mildly short of breath. No chest pain. History: patient only knows that he has heart problems. Meds: digoxin, Lasix, ASA Allergies: none He has clear bilateral lung sounds with a sat of 98% and a RR of 20. His BP is 82/56. So what’s up with this guy’s EKG? What are the appropriate treatments? “Don’t worry, sir. You’ll be just fine. Don’t hesitate to call us back if anything changes.”

"Oh, and by the way, he also had a mechanical fall from ambulance height onto pavement."

Thanks everyone for all your posts. This was fun! I encourage others to post more scenarios because I think it's a great way to learn. The patient is suffering from cauda equina syndrome caused by a herniated spinal disc. Check out these very interesting articles below... http://www.emedicine.com/emerg/topic85.htm http://en.wikipedia.org/wiki/Cauda_equina_syndrome http://www.neurosurgerytoday.org/what/patient_e/cauda.asp

ER Doc wrote: "Any saddle parasthesia? Incontinence? Reflexes?" Okay, so you do a complete exam of his legs. The first thing you notice when you pull the blanket off is that he's incontinent, which he's quite embarrassed about. You check range of motion and ask him to describe where he feels pain and numbness. He says the pain is mostly in his lower back but also shoots down to his legs. He can move his legs but he says they've been getting progressively weaker. You ask him if he also feels numb between his legs in the area of his genitals and he says yes to that also. So these are all red flags for what? (ER Doc already knows.) By the way, is it realistic that someone with all this going on would not want to see a doctor and would not volunteer all the information about what's going on? Heck yes! This all happened to my cousin when he injured his back playing tennis. He didn't want to go to the hospital, and his wife had to call his doctor and have his doctor plead with him to call for an ambulance.

Here's what the actual abd exam reveals: http://www.grimmemennesker.dk/data/media/1...-beer-belly.jpg The abd is soft, nontender, nondistended. Yes, he is complaining of some numbness and weakness to both legs. Also now complaining of pain shooting down to both legs, but mostly it's his lower back that's killing him. As per the previous post, he's got good pedal pulses and cap refill.