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You have to balance the fear of anesthesia awareness with the need for sympathetic stimulation. See the next thought below. So the thing to remember is that paralytics actually have VERY little effect on sympathetic drive. The sedatives however, do. Reduce pain and anxiety, you remove a portion of sympathetic stimulation. There's a couple of likely possibilities as to what happened in cases like you mentioned, one is they weren't watching K+ when pushing sux (which is why I don't miss the stuff at all), another is that they removed the respiratory compensation of a severe acidosis leading to cardiovascular collapse. The final likely possibility is that the sedation reduced the sympathetic stimulation enough that converting over to positive pressure in the chest knocked out all venous return. This is one of the reasons to hold/severely reduce the dose of the sedatives. Agreed. Yes and no. We don't like to "write patients off" because we're supposed to "save" people, but sometimes you've got to realize futility and not waste the resources on it. I recently had a discussion over a very similar case with former paramedic/med student. He reminded me that blood is a very finite resource, especially in this type of setting, and dumping it into a patient that's not likely to live is a misuse of it. You can't focus completely on the patient that "might be", but it's just as irresponsible to not at least consider it in a case like this.

2R, Your pt hx is very, very general. I am assuming her back pain was lower, considering she weighs 300 lbs. Upper back pain is a whole different animal, but you did not say. You have no documentation of lung findings, or her mental status. 96% sat in a morbidly obese pt is ok in my book, if they are standing up talking to me, holding a decent conversation. Does she have COPD, you didnt say, but one would have to assume she does because of your statement about her house being filled with smoke. Again, no lung sounds were disclosed. In COPD exacerbations, you have a respiratory alkalosis in the begining from hyperventilation, (compensation) followed by a steady rising hydrogen ion concentration as they worsen, so - your statement only carries so much weight with her Etco2 being 11. I am also assuming that you have placed this pt on the litter with her feet on it as well. If she is fat, guess what, all that adipose pushes his or her lungs up into her throat, hence the decreased sat. Treat the pt not the monitor, and please before bashing a seasoned medic, make sure you have your ducks in a row. I am sure he or she cares, this seems like nothing but drama on your part. I am sure he or she knows after 20 to 30 years of experience "sick or not sick". JB

Not specifically to this scenario, but I have to disagree with what has been said by a few people here. I do not think I would necessarily call medical control for this patient unless something in her presentation made me uncomfortable leaving her alone. Crochity, you say that anyone over 70 with a medical complaint should be transported. What are you defining as a medical complaint? I don't know to many people over 70 who don't have a medical condition that they live with day in and day out, that sometimes flares up. Here is what I would do/ want to know were I in a similar situation First, instructor, you say carotid pulses are present. What about radial pulses? I assume they were as later you state a pressure with 108 systolic. If I am having trouble ascultating a pressure, I attempt to get one by palpation, then either have my partner, or the monitor try. After obtaining baseline vitals with the pt on the floor/ how we found her, and doing a basic assessment, I would then assist her to sitting. At this time I would reassess vitals, check how she is feeling, and do a more detailed exam. If nothing is hurting and vital stay the same, I would then assist her to standing. How does she normally walk? Independently or with a walker? Does she use a wheelchair for distances? If she is is able to ambulate around her house (get to and from bathroom/ kitchen), I would be comfortable letting her refuse, while encouraging her to call her doctor for an evaluation for frequent falls, and having a plan for friends/ family to come over to stay with her for a while. (NOTE, this is based upon her earlier statement that falls are due to feeling unsteady on her feet/ increased weakness, NOT dizziness...). If she does not have a walker, she probably needs an evaluation for one, which they will not do in the ER. If I get pt to standing and she is unable to ambulate independently/ with her walker, I would have her sit back down and we would have a discussion. I would tell her I don't feel safe leaving her at home alone when she can't get around. What if she needs to use the bathroom again, how will she get there? I will try and point out realistic problems that she can/ will have if she is unable to walk. I will encourage her to call her family/ friend, and if it is OK with her, explain to them what is going on, and try and have them convince her to be transported. If pt is adamant she will not go by ambulance, I will bring up the option of having family/ friends drive her to the ER. If she is still refusing transport, I would document and have her sign a refusal, and have someone else present sign as a witness. In this scenario, I would consider calling med control, but unless she has a physical complaint other than increased weakness, I doubt they are going to want anything to do with it. As far as how to teach your student/ new person this, sometimes the best thing to do in these situations is watch. I am still a relatively new provider, and I am thankful that I had the opportunity to watch different EMTs and medics with much more experience then I deal with these types of scenarios, so I got to pick out parts that each one of them used, and put them together in my own style. Then when I became more comfortable, I started running the entire call on my own, with them watching (actually they said "we will not do anything including getting vitals unless you specifically ask us to") only jumping in if I was going to miss something major.

I would feel that unless I witnessed the verbal recension of the DNR that you should not provide life sustaining care in the patients current state. The way that I have always understood a DNR to work is that it is a legally binding document, the only way it could be rescinded is if another legal document revoking it was presented, the daughter had either medical or a durable power of attorney, or the patient states their wishes in front of you and another credible witness (eg. your partner, or the doctor). The patients daughter may very well concur with the plan however in absence of said power of attorney there is no legal power that the daughter wields. Now as far as the transport is concerned...as a BLS provider in my case I would refuse transport because I could not provide reasonable comfort measures based on the patients current needs. If I were an ALS provider I might consider the transfer to the "city" HOWEVER I would have the family be prepared for the worst case scenario and understand that the patient may not make it through the transfer. As far as the nurses statement "Dr. says he would like you to stabalize him and get him to the city ASAP.", I would not do any such thing with out a WRITTEN ORDER because as we all know if it is not written down it did not happen.