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After doing my time in Hell (aka NJ), I got hired with a County Fire Dept in Fla, starting June 21st. I know many look down upon Fla Fire Depts, and those that work for them, but this is a huge chance for me to actually be a medic, a fireman, and actually use my judgement during patient care, not a Dr many miles away, who I talk to over the phone.

Ah, what?

Here is a scenario meant to expose providers to a patient population that is given no coverage in most of EMS education. You respond to the park in a poor area of town for a 20 year old Brazilian male with shortness of breath. HPI: Patient was playing basketball with family while at a picnic, when he became so short of breath he had to immediately stop playing. Sitting down and relaxing did not palliate the sensation and family requested EMS. He tells you that he has experienced mild short of breath for the past 6 months or so and has found that sometimes he is breathing fast even after simply walking to his house from his car. He has been hoping that he had a chest cold or allergies and that it would go away by itself. However, today it is much worse and he is worried. Mother on scene says patient has never been athletic and always tired easily which has always been chocked up as just not athletic, however she has noticed a decline in his condition the past half year. He has not seen a physician because of socioeconomic reasons, and has never really had a primary care physician. Prior medical history: None. Patient does not see a physician. Prior surgical history: None Allergies: None Medications: no prescription or OTC/vitamins/supplements taken. Family history: diabetes and hypertension on the father's side Social history: Born in Brazil at home, and immigrated to the United States 8 years ago. He and his family are impoverished, and the patient works at a local car body repair shop at the front desk. He does not drink or smoke, and lives with family in a house. Review of systems: General: no fever. decreased exercise tolerance past six months. Patient is easily fatigued. HEENT: gums bleed easily when brushing teeth. slight yellow discoloration of sclera. Otherwise unremarkable. Cardio: patient states that he has had to keep his shoelaces untied because his ankles have swelled recently. Pulmonary: shortness of breath on exertion and very occasionally at rest. no fever, night sweats, cough. no asthma or wheezing GI: occasional dull pain in the RUQ. otherwise unremarkable. physical. Vitals: radial pulse: 100 bpm and regular. BP 130/84. resp rate 24, adequate depth. temp 98.8 F. HEENT: Jaundiced and slightly blood injected sclera is noted. bilateral jugular venous pressure is elevated to cause obvious distention as 45 degrees. some cyanosis noted around the lips. Pulm: Lungs are clear to auscultation. Chest is symmetrical and atraumatic. No scars noted CV: A palpable right ventricular heave and thrill are felt at the left sternal border. A grade II-III holosystolic murmur, slightly harsh, is heard at the left lower sternal border. All peripheral pulses are easily palpated and are adequate. GI: liver span is consistent with hepatomegaly by percussion and scratch test. Extremities: Finger clubbing is noted, along with slight peripheral cyanosis. some pitting edema is noted at the ankles. Patient has several bruises on his legs, says he is bruising easily. Your EKG monitor shows sinus tachycardia with no ectopy in lead two. Finger oximetry is 92% on room air. You can ask for whatever study you would like. I will even give you labs if you ask for specific ones. What is the immediate field diagnosis? What is the underlying pathology and what is the pathogenesis of the recent decline in his condition? What is the field treatment, and what is the definitive treatment? Prognosis? 12 lead

Early menopause! Spot on my dear Watson. JK.. Our patient's present pathology is rare in the developed world, however the causative lesion is common but is usually corrected in childhood. If you were able to know somehow, you would find that our patient has had his heart murmur all of his life. In fact, the murmur used to be louder earlier in his life and has recently quieted a bit, with the thrill diminishing as well when his symptoms became worse. However, our patient was born at home and has never had proper medical care. Being in a third world environment in rural Brazil, he never had well child visits with a pediatrician and his pathology was never discovered when it could have been treated. With a holosystolic murmur at the left lower sternal border, an RV heave, hepatic congestion with other signs of RV failure, and RV hypertrophy on EKG you can infer that the patient's underlying congenital heart defect is an isolated, moderately sized ventricular septal defect. VSD is the most common congenital heart defect, and about 1% of all live babies are born with congenital heart defects. You might also consider tetralogy of fallot, however you could rule that out based on his age (20), because he would probably have died before his second decade of life with untreated tetralogy. Further, our patient has been acyanotic most of his life. A moderately sized untreated VSD would account for the delay in full blown RV failure. With the recent cyanosis and low oxygen saturation, along with the marked right axis deviation on EKG and the dilated pulmonary trunk on CXR, you will find that the untreated VSD has progressed to eisenmenger's syndrome. For most of his life, the hole in the intraventricular septum has caused a left to right shunt. The larger and more powerful left ventricle forced oxygenated blood through the defect and back into the right ventricle, where it was again pumped into the pulmonary circulation. Over time, the increased pulmonary blood flow caused restrictive changes to his pulmonary arteries which progressed to pulmonary hypertension. The right ventricle had to pump harder and harder to overcome the increased pulmonary vascular resistance, causing RV hypertrophy and eventually failure. The enlarged and now powerful RV reversed the shunt, and now deoxygenated blood was forced through the defect into the LV and pumped into regular circulation causing the cyanosis. Eisenmenger's syndrome is a late complication of untreated VSD where the shunt (left to right) is reversed to become right to left. The pulmonary hypertension is irreversible, and fatal. The erythrocytosis is a compensatory mechanism for the chronic hypoxemia. Jaundice and coagulopathy are secondary to liver dysfunction, caused from the chronic hepatic congestion from the RV failure. His prognosis at this point is actually quite poor, and death will probably occur within a few years even with treatment. Definitive treatment for eisenmengers is a heart-lung transplant, but survival past 5 years after transplant is quite rare. Why did I write this scenario? You will probably never encounter eisenmenger's syndrome in your career. It is helpful however to understand the late sequelae of untreated VSD, because VSDs are other congenital heart defects are very common. But the point of this thread was to introduce you to a patient population you will start seeing of very soon. A patient population that is rapidly expanding, and one that is new to all of us. Because of the advancements of modern medicine, children with congenital heart defects are now living into adulthood, and this is a very new development. It will not be uncommon for you to care for young adults who had very complicated open heart surgery to cure or palliate congenital heart lesions. JEMS wrote an absolutely useless, horrible article on congenital heart defects last year. The author went in with the idea that EMTs and paramedics were too stupid to be taught about the physiology and altered physiology of the heart, so instead attempted to broadly classify the many different defects into neat little "cardiodromes" dumbed down so that we could all understand. He royally butchered the whole thing and probably left most readers scratching their heads and turned off of CHD.

Okay then, guys this thread has run it's useful course. Perhaps we can let it die a relatively peaceful death? Take care, chbare.

They call we haul. Even if there "emergency" seems nonemergent or even nonurgent that is not our decision. It is better to legally and ethically to just take to patient as they wish no matter what we think. I never discourage a patient for transport. The ER may say something to you which in my opinion is uncalled for. I always respond with "they call we haul" or "they ask for your facility by name." If needed I take the time to explain our role, but I have yet to find a nurse that doesn't understand it. They know we have no choice in the matter just sometimes feel the need to vent as we all do.

Yeah 4c6, I took it that you were being an asshole to this kid too, and was surprised by it. I'm guessing when you reread your topic, description and post that you can easily see where people got that idea. I do believe your posts show you not to be that asshole though...just sayin'. What I do have issue with is those that have stated, "If it compromises pt care, I'm cutting it off." as if cutting or not are the only options available. In my experience people often cut off clothes for the same reason they can't wait to get to c-spinin', because it makes them feel very heroic. All of my trauma pts get near naked before going on a board, but rarely do I cut more than tshirts. You know who I love to cut the clothes off of? Those people that explain to me how bad they are going to kick my ass if I do. You know who I really, really, hate to cut the clothes off of? Homeless people. My basic partner, who teaches me something new just about every day, and I had a homeless man that had been attacked and stomped to whale shit. He was wearing a nice warm leather winter jacket and I friggin' hated the thought of cutting it off, though there was no question that in needed to come off. I finally made up my mind to do so, shears in hand, when my partner simply reached over his head, grabbed the back of his coat and the collar and pulled it over his head without moving him an inch. He got a thorough assessment and got to keep his much needed coat. Things rarely, if ever, are black and white. Protecting peoples lives is important, but so is protecting their property, and the trust that showing that respect exemplifies. Let's try and think outside of the box when we can... Dwayne

You mean all 120 hours of the first aid course that constitutes EMTB in this country? If we want discretion to make transport decisions in the field then we need to commit to a proper education. And I don't mean a 7 month medic mill or even a 2 year associate degree.

Chris I have to say I started to write a post about cutting things nt needing to be cut but after I read your explanation I have to say I am sorry for jumping to conclusions anyway I am all for cutting if its necessary. And I am sorry but who are you and how do you get off putting down Wendy, Almost every post wendy has very valid points very rarely to you see people putting her down. Her post was appropriate prior to a gross misunderstanding by many people being cleared up.

Just standing up to Moby and his friend. Both fear my posting. It wasn't just about forgeting the protocol. It was his attempts to misrepresent that they were EMR protocols. Then he misrepresented covering them in class. It is really the obstruction and efforts to cover his tracks. Read the postings. Both Mobey and his friend got heated about my posting. I think I hit a nerve. I think there is a history there. Read the postings. Both Mobey and his friend got heated about my posting. I think I hit a nerve. I think there is a history there.

Thats not entirely true. There are members taking this discussion too personally. Read the responses Mosbey's id dishonnest: "From where I sit it looks like you might just be lining some lawyers pockets to stand on a soap box for a little while". Look at some of these posts. Prettey paranoid. Just can't take someone responding to their posts.