Jump to content

Recommended Posts

Got onto this one late int he game. I did read everything so Im pretty caught up on it. Please remind me not to get sick in NYC :rolleyes:

OK from my BLS perspective... (keep in mind I have a 40 min transport time by ground) (I would love to fly this guy actually)

I am droping an NPA and starting with 15l NRB. I dont think CPAP would be a good idea because of the subQ air already. Might think about a VERY gental BVM.

ALS would be called and meeting enroute. This is a lights, sirens, airhorn call and telling my driver to open the diesel bolous. I want this pt to get to the ER as quickly and safely as possible.

Taking vitals every chance I get.

I want him sitting up to aid in the breathing but looking at the shock side I am going to ease the back down slightly and get a pillow under his legs.

Watching the secreations and suctioning if necessary. Definatley saving some for the Dr.

Depending on his temp I would put ice packs under the arm pits to try and bring it down if its very high. If its not danerously high I would just monitor it to see if its going up.

Other then that I am at the end of my protocols until ALS arrives and I assist them with whatever they need.

Link to post
Share on other sites
  • Replies 69
  • Created
  • Last Reply

Top Posters In This Topic

Top Posters In This Topic

Popular Posts

I'm well aware of the levels in NYC and have worked with many EMTs and Medics on LI who also worked in NYC. Again, you failed to answer the question. Do you work for FDNY, a hospital based service o

Never getting sick when this dude is on duty... If he even works for NYEMS

And the fact that it's ok to cheat on a spanish test but it's not ok to cheat on an ems test or some stuff like that. MariB and Mike both summed other items up pretty well. I would suggest y

Well this is an interesting scenario. It's always great to call in ALS but alas I do not have that luxury. Since I'm so efficient I have all my equipment with me :)

As I am doing my initial assessment ABC's, I will ask my partner to get the O2 on, I am choosing a non-rebreather at 15 lts. and to get the cot ready.

As soon as this is done my patient is getting onto my cot ASAP in a sitting position unless he goes unconscious then supine it is.

In all reality getting this patient to the ER and getting notification to them ASAP is my priority.

I can help with the secretions with suction but I need to be careful not to get to suction happy or I can wipe with a gauze to help.

With the hx that has been given I am also suspecting a stint has dislodged from the infection, so that is going to tell me that there is a chance the air is not necessarily going into the lungs but the chest cavity. I think that using a BVM may be detrimental in this case as the pressure may cause more damage, but if I had to it would be very gentle.

I can only use a King if the patient codes, so if he goes unconscious I am more apt to try a nasal airway first.

I will continue to monitor and reassure this patient all the way to the hospital and stay, help in the ER and truly hope for the best.

What is air to Chair?

I think instead of supine, how about recovery position to help aid in letting secretions drain, then if you suction maybe you could suction his left cheek where it is draining and may not have to irritate the infected areas? I'm guessing his pharynx, tongue, and everything at this point may be affected at this point. .
Link to post
Share on other sites

I think instead of supine, how about recovery position to help aid in letting secretions drain, then if you suction maybe you could suction his left cheek where it is draining and may not have to irritate the infected areas? I'm guessing his pharynx, tongue, and everything at this point may be affected at this point. .

I did think of that, but this is why I didn't go that way.

The patient is going to be able to breath easier in the original sitting position, moving them into the recovery position in a moving ambulance is unsafe for both the patient and myself, I would rather not pull over and take the time to do that if it means a delay to the ER , and if they code I am ready for that scenario.

Link to post
Share on other sites

I did think of that, but this is why I didn't go that way.

The patient is going to be able to breath easier in the original sitting position, moving them into the recovery position in a moving ambulance is unsafe for both the patient and myself, I would rather not pull over and take the time to do that if it means a delay to the ER , and if they code I am ready for that scenario.

I see.

It isn't so bad if you have to to loosen the straps and start wedging blankets under them to get them onto their side. However, it takes some practice. You can then pull them out to get them back on their back.

Link to post
Share on other sites

I think the more logical question to ask is this, where do you want those secretions to go? Do you want them to drain out via the recovery position or to have the possibility of going elesewhere with this suspected perforated trachea or even back down into the lungs?

  • Like 1
Link to post
Share on other sites

I can agree on those points. This is a case where you won't find any studies or textbooks to support or refute your treatment. If whatever you do works, you will look like a hero. If whatever you do makes the pt worse, people will criticize you. Another thing to consider is that this stent may have involved the junction of the mainstem bronchi and placing a tube will do nothing. Maybe we need to think about putting it in the right mainstem, beyond where the stent might have been. Granted we are shutting off one lung but again, it is an option.

Hello,

How true.

This case was based on a patient we had in the ICU. Not an easy situation.

The patient was transported to a local ED with a NRB, low stats and his airway was managed by anesthesia.

They tube him with a scope and lined him.

He had a perforated trachea and a laryngeal tear. This was repaired by the thoracic service. He also had a complicated course in the unit because of sepsis, CHF (he had a STEMI), and a VT arrest. Lucky, he got well enough to go to the step-down and I am not sure what happened after that.

He also had stenosis and only would take a 7.0 tube.

I learned a great deal. I had considered the risks of PPV or CPAP. I think I would have tried a NPA and some gentle BVM to pink him up. As for position I would have kept him sitting up despite the pressure. But, didn't think bypassing the whole mess, if need be, by intubating the right lung only.

Again. This cases has many different possible courses.

Oh, I would call ahead as well. =)

Cheers

Edited by DartmouthDave
Link to post
Share on other sites

Can i just say i came to this very late but this is one of the best discussion ive seen here for a long time... bless your cotton socks!

Link to post
Share on other sites
  • 2 weeks later...

Excellent thread. Sorry I missed it earlier. Very good stuff!

Wendy

CO EMT-B

RN ADN

Link to post
Share on other sites

Same here, great thread, Made me do some thinking, thanks

Link to post
Share on other sites
  • 2 weeks later...

Going to interject despite not having time to participate fully, as well as being really late to the party.

Something I'd like us all to think about...miscusi. Man, we've kind of taken to being rude to anyone that doesn't share our opinion, or that we feel superior too..particularly if they are foolish enough to 'try', thus risking giving us a big stick to hit them with. Often insecurities are temporarily mitigated with bravado and false self confidence...but there are still real people under the facade.

I'm pretty confused by the responses to him/her. It sounded to me like s/he was saying, "This patient has been alive more than a month since the surgery and two days since the metal episode, so all things considered I'm confident that he will live regardless what I do, for the next ten minutes until I can drop him at the hospital." What would be a more productive, realistic attitude if you work in a 'do nothing, just transport" type of system?

If that is your system, and that is what you're used to, then what other things would we have liked him to have said? Granted, he didn't get the way that these scenarios are played, but it appeared to me that he tried over and over to explain his point, and it seemed pretty clear to me, but too many had already started to celebrate that "He gave us a stick and now I get to be him with it!" Not knowing how scenarios work didn't use to be a sin.

I guess what I'm saying is, what if you'd have tried to see his point of view instead of just insulting him out of the thread? What if he gave those answers because that's all that he knew how to do? Was he, or us, or the thread improved by continuing to tell him how stupid he is until he finally quit? Where is the joy or the challenge in that? Isn't the joy and challenge in helping that type of person, exactly that type of person, to move forward? Leaving them better than we found them?

I've given plenty or reasons to be called an idiot, and give more in almost every post, yet my friends here always find a way to push me back onto a productive path...It breaks my heart to see how this thread went early on. I am confident that if even a small effort had been made that his point of view could have been seen and appreciated..it just didn't seem that complicated to me. I'm not saying that I've never had my ass kicked here, nor participated...I guess I was bothered by the extra exclamation points during the insults.

It seems like I see more and more here that we protect our brothers and sisters that have been here for a while, but often are wicked hard on the newbies...I can't prove it, I'm not even sure that I'm right, and perhaps this guy/gal has a history that I'm unaware of that has earned them that type of disrespect from others...I just hate to see it. And it does appear to me, from my way of reading, that he wanted to stay and participate, that he wanted someone to give him the slightest reason to change..but he was asking too much. Again, to my reading, of course I could be dead wrong.

All comments as just me, not as a mod...I love you all, consider nearly every regular poster here to be my friend, but sometimes it seems like we accidentally, or on purpose, act like a group of bullies and that type of behavior represents, in my opinion, the very worst of EMS at all levels.

  • Like 1
Link to post
Share on other sites

×
×
  • Create New...