Ok, here's the situation...

[vs-eh?]

...my parents went away on a weeks vacation, and...They left the keys to the brand new porsche, would they mind? Hmmm..well, of course not...

So, I had an interesting set and thought I'd share my tale of 3 patients. Sit back and enjoy. Hold all comments to yourselves because I don't care what you think.

THIS IS LONG SO GIVE YOURSELF 7mins and ummmm 31secs of time...

Patient 1...

Called the a NH on a DELTA for a man in his 70's, unresponsive, diff. breathing "like sleep apnea" as per NH. LOL...so I'm thinking "sleep apnea"? He's probably pulseless and agonal...

So we get there...Man is unresponsive and in cheyne stokes resps (look it up if you don't know) which I had never seen before. He is pale, cool (tympanic 34C and cool to touch) and diaphoretic. He was last seen ~30mins prior with zero c/o and normal mentation (GCS 15 apparently though normally abrasive). He was generally well x several days. I don't remember specific medical conditions, though he had recent hip surgery including an MI during the operation.

Vitals - Pulse 70's, BP - 62/40, sat 97% RA, BS was normal (don't recall), chest was clear with no adventia. NSR on the monitor (no 12 lead), pupils PEARL at like 3?

Meds - Don't recall specifically but no antibiotics and no beta-blockers/anti-dysrthymics...

This patient is a DNR...

So I'm thinking maybe sepsis (hypotension with no compensation, and he probably had been sick for a few days) and increased ICP (query CVA with the cheyne stokes maybe bleed affecting pons/medulla). inferior MI with R vent. involvement could be on there too I guess. So NPA, NRB, monitor, IV (he had about 700ml prior to hospital arrival with zero HR/BP change). I was going to ask for dopamine but given his DNR I decided no...I also decided no PAI (he was becoming more rousable during our tx with some purposeful movement) always considering the DNR.

Patient 2...

Called for an ECHO. Male, mid-40's collapse in a mall, unresponsive, shallow breathing, mall security had a PAD with one "no shock".

Noted - EMS was called there for this guy ~30-45 mins prior because mall security "didn't think he looked good". Paramedics arrived, and he basically told them to F-off, and was threatening to sue for hastling him. All they got was name and DOB. He refused all assessment. Crew actually attended the call to back us up and said he was GCS of 15, CAOx3, with no noted mental deficits or distress.

Witness - Buddy was walking with a walker and just fell backwards smacking his head. Unresponsive post fall with shallow breathing. No noted seizure activity, no obvious distress prior.

So we get there, buddy is being attended to by mall security with a PAD on him. Unresponsive, being ventilated with a face mask thing, no CPR in progress (and never was). He is breathing about 6 a minute a shallow, strong rad pulse (obviously never arrested, FR aren't taught pulse checks anymore?). So OPA/NPA and BVM tolerates everything good compliance, good a/e, initial ETCO2 like mid/high 50's with a good waveform. Vitally he is stable HR - NSR in the 80's, BP - 120/84, BS - normal, sating well, pupils like 2-3 slow, he had matted bloody hair to occiput difficult to qualify injury but nothing grossly unstable...So hmmm right? We had no PMHx besides some obvious neck problem (flexion/stiffness/and bandaging for chaffing obvious chronic issue...great tube eh? Go go lighted stylet). So whatever differentials are pretty big but head injury/CVA/seizure or narcotic OD (likely polypharm given vitals). Seizure would seem odd given his tolerance for the airways and vents for ~10mins. CVA vitals are unusual...

So a/w and breathing are good, no need for a tube this instant, IV is started, and c-spine is underway. I am standing there already prep'd for intubation and have some drugs out just in case. I give him pre-intubation lidocaine due to query head injury as the issue. Shortly after doing that, he starts biting/gagging on the OPA and fighting the bag. Take out OPA and he starts coming around to about a GCS...oh....8ish? By the time we got to the hospital he was GCS 8-9. He kept saying "sit me up" and not answering any questions, also he wouldn't move his arms/legs though it was obvious he had pain sensation...

Patient 3 (The weirdest one)...

Called for an ECHO again at a residence. This time for a choking...Now, anyone who has worked in EMS for a bit, especially urban, knows that 99% of "chokings" are BS. They are either resolved prior to arrival, a person coughing and talking who just needs a little coercion, or the "I took a vitamin 20mins ago and it seems to be stuck in my throat..." As they are gabbing away about there 6 grandkids and such...Very very rarely do they require BLS and ALS intervention...

East Indian Male, mid-80's...Less than 5 mins prior to arrival pt. had taken a bite of his dinner (roti). Less than 10 secs following that (with no warning) patient falls to the ground...no coughing, no seizure, no "universal choking hand sign", nothing...Pt/ had no c/o prior, generally well x several days, and no medical hx. That's right folks, mid-80's and NKA, NO MEDS, and NO SIGNIFICANT MED Hx (surgery on knee and gall bladder like 10+ years ago thats it) and a 50+ year smoker. For an east Indian male (high risk for coronary) that is good...

So our arrival (right on top of this, like < 2 mins). Pt. conscious lying on floor, breathing, no real distress, no audible stridor/adventia. a/w was maintainable by pt. no tracheal sounds on auscultation, = a/e bilat A>B, is breathing somewhat shallow. Vitals - 98 on RA...but he desat to 94 soon after (recall smoker), HR - 150-160 atrial tach, BP - 190/100 L arm, 220/100 right arm, sating 98 now on a mask, BS - like 9 something...physical had a bit of abdo distention that the family said was unusual. Mentation - Patient did not speak english but would not talk to family when asked questions, he did have some movement in extremities but nothing fantastic...So whatever monitor, O2, IV (no luck, he had veins but no flash and no advancement, took the hospital a while once we were there too).

CVA? MI? Meh...

We sit this guy up and move him to the stairchair...Sit him down and he lets out this HUGE belch and out comes this 3/4 palm size piece of Roti. Lol, my partner and I are like huh? So here is our hypothesis...

He may or may not have actually had a tracheal obstruction. For whatever reason it dislodged from the trachea prior to our arrival and rested either in the hypopharynx or (more likely) in the esophagus. He had some how managed to swallow a bunch of air (would equal the distention). This obstruction I guess could have been intruding on the posterior trachea cause a partial obstruction, but clinically, there was really nothing to suggest that out side of the hx. Certainly nothing to suggest BLS or ALS a/w intervention.

But ya...once the roti was expelled, he started to perk up. Tachycardia resolved....BP fell...started talking to his family. By the time we got to the hospital, he was basically his old self as per family and hemodynamically stable. Weird eh? Tach and hypertension was some kind of laryngeal stimulation/hypoxia? Meh, who knows...

We were laughing because we weren't getting any patients who "fit" on this set. It's good though, I like it...

Comments? (Yes, I really really want those comments).

[nuEMSgurl]

...if the first crew that attended the second patient stuck around a bit-like at a distance. Here, if it's not a big service, we can stick around a little bit-see if there might be anything else we observe that might help in the event that we do get to treat him after all. If it is a big service, you can just about forget the crew sticking around. My guess is that they probably didn't, but I could be wrong.

[Dustdevil]

Comments? (Yes, I really really want those comments).

Any system that utilises, or even believes in tympanic thermometers sucks.

Any system that does not carry or routinely utilise ANY kind of thermometer sucks even more.

[Refer to the "Inappropriate use of Lasix" thread for explanation.]