What would you do?

[Kiwiology]

Great ... I disappear into internet land for six months and come back to this?

Hang on; *scoffs down a handful of lorazepams .. there, thats better, now, let's have a nosey doodle at our patient shall we?

What about some ketamine and a bit of non invasive ventilation? If access it a bother we can give ketamine 4 mg/kg IM.

I don't really want to tube her and have to tie up an ICU bed for the night.

[Just Plain Ruff]

Well a phone call to the medics training director or supervisor would be in the best interest of this medics career direction. She inappropriately treated this lady. Although the protocols state 2mg there is not a single person here on this forum who would have given the patient the full 2mg of narcan.

I'll bet that her medical director would have something to say about the full dose as well.

The fact that the medic scooted out as soon as the heat started just proves to me that the medic knew that he/she screwed up.

But no matter what you say to the supervisor/training director and it gets down to the medic, that medic I can guarandamtee it will say that the doctor just had it out for me.

Too bad that patient got a piss poor medic to take care of her.

[paramedicmike]

How long did she make it this time before being intubated?

This is a good case for discussion. Thanks for bringing it to us.

[scubanurse]

I'm not 100% sure of this but I'm not really opposed to central line/tube unless she wants something different.... what's her DNR status and desires for care?

[paramedicmike]

I don't want to tube her, either. For some reason, though, I kinda' see it moving in that direction.

[ERDoc]

She is full code. Based on her lethargy and inability to remove the mask, she is not a BiPAP candidate. Her status is decreasing so the decision was made to intubate her. She is easily tubed with a 7.5 with no complications. The nurses are getting concerned because you have asked for a propofol drip and their IV seems to have infiltrated. They've had the best of the best of the best try for access and it has been unsuccessful. She was recently hospitalized so the admitting service will not take her without a CT angio thorax. What is your next step?

Edited October 14, 2013 by ERDoc

[island emt]

Anyone look at her feet for a nice plump vein , or an EJ ???

If those are out then it's probably time to think about a central line since you ER docs are so talented. :-}

[chbare]

Place an IO and begin infusing the sedatives and analgesics needed to keep the patient comfortable. Place two IO's if we need additional access. We can stabilise her and let the intensivist place a central line in the unit if needed.

[paramedicmike]

IO access is a reasonable and quick option. IJ or subclavian can also be placed. Get the appropriate sedatives and analgesics running. If the admitting service won't take her without a CT then order the CT. She has to come in and she can't sit in the ER all night.

[chbare]

Yeah, plus you may as well spread the love and give the admitting doc something to do. If you are really lucky everybody will complain about going IO even though it's a quick, safe and effective option...but that is another discussion.