ERDoc

You have obviously read my scenarios before. You contact medical control, but your doc is busy with a booty call in the call room. So, you have no MD to consult, do you or do you not give the Calcium?

She is awake and talking, fully oriented. She does have a history of afib which is why she is on the Dig. Other than a funny feeling, sha cannot describe the sensation in her chest. You cannot contact a physician so you must make the decision to give or not give bicarb. Yes, albuterol does help to push the potassium back into the cells.

The pulse is present in all extremities, but it is thready. No abd tenderness or masses.

Hopefully not with a rectal thermometer!

We have a winner!!! Seriously, someone has got it. The kid has no trouble swallowing. His EKG looks fine. Someone wanted to draw some blood, so this was done. You note that his blood looks brown in color. His lung sounds are still clear. He does not feel like there is any swelling in his airway. You are able to reach Dr. Johnson who tells you that it was a pretty simple needle aspiration of a peritonsilar abscess. He used Hurricane (benzocaine) spray for anesthesia and did not start the kid on antibiotics. He starts to tell you what the problem is but the battery in his cell phone goes dead and he is too busy cruising down the A1A in his Porche to stop and find a pay phone (if they even exist anymore).

Nothing you do gets the pt's sats above 85%. Radios and cell phones are down. The mother tells you that the kid had a sore throat for the past few days. He saw his primary who told him there was an infection in the left tonsil that needed to be drained. The sent him to a Dr. Harry Johnson. The mother hands you the card and it says he is an ENT specialist. She says that they sprayed his throat with some numbing spray and then used a needle attached to a syringe to drain some "ugly yellow looking stuff". EKG looks fine.

Bad snow storm, no one is flying. No trains are running either.

You are 100 miles from the closest hospital and due to too many accidents, your company has placed a governor on the ambulance that limits the speed to 30 mph. :twisted: Nice try, but you cannot pawn this one off on those sexy ER doctors.

Yes they can. The oropharynx appears clear and patent. As I said before, there is a small puncture to the left tonsil. No change with albuterol.

What do you want to do for this kid? I will not confirm nor deny the diagnosis until others have had time to jump in.

No fever. He is able to lie flat with no change in his symptoms. His voice is not muffled.

I'm not confirming nor denying that the EKG shows hyperkalemia (very US govt like of me). She tells you she has been peeing fine. She takes Kdur, but is taking the same dose she has for the last 2 years. She says that her doctor decreased her lasix dose a few days ago. She then tells you that she is feeling worse. She is more lightheaded and has a funny feeling in her chest. Her repeat 12 lead is unchanged. Her HR is the same but her BP is down to 88/56. You drop in the 200cc bolus with no chage in her BP or lung sounds. What else do you want to know/do?

The kid states that he is having trouble breathing. He denies any chest pain. No history of neck trauma. He tells you he went to a doctor today and was told that he had an infection in one of his tonsils. He said that the infection was drained with a needle. He has not had anything unusual to eat. His GCS=15. There is no signs of trauma to his neck. When you look in his throat you can see a small puncture to the left tonsil with no drainage at this time. He appears distressed but not anxious. He has 3-4 word dyspnea. His lungs are clear bilat with equal air entry. He is able to take a deep breath without difficulty or pain. There is good chest movement. Skin looks cyanotic. You put him on high flow oxygen with no change in his symptoms and his pulse ox goes up to 85%.

You are called to the residency of a 16y/o who is stating he can't breathe. The boys mother greets you at the door and tells you that for about the past 30 minutes he has been short of breath and it has been getting progressively worse. She tells you that he was at the doctors this morning for a sore throat and wasn't having any trouble breathing at that time. He has no medical problems or allergies. You walk into the living room and see an african american male sitting on the couch in obvious respitatory distress. RR 28, P 118, BP 108/72, Sat 83%

This whole story just bleeds stupidity. I understand why they have a zero tolerance policy, but come on. Schools today are not the schools that most of us grew up in (I graduated HS in 1993). I think the girl should have been disciplined, but to arrest her and charge her with a felony??? To bring a steak knife to school in today's world is just plain stupid. Even a 10y/o should have a clue when it comes to things like that.

Dwayne, I'm just messing with ya. Good question about the ntg, but no she has no taken any. Look above for when you get when you finally hook up the monitor.

"You know, now that you mention it, I do feel a little nauseous, but I haven't thrown up." Skin exam is normal. Temp is 98.7 (you can make that rectal if you are so inclined). Electric stove. CO detector has not gone off (the batteries are working and FD has tested with negative results).

Orthostatics are negative. Whatever stroke scale you are using this week is normal. You cut down her oxygen to 3 LPM. Your rhythm strip looks like this: So you get a 12-lead and this is what you see: Does anyone want to get a better history and perhaps touch the patient before we start running whatever testing we can think of.

Sitting in a chair, calm, nontoxic appearing, skin warm and dry A&O to however many points you use Yup She looks at you funny, "I don't have any chest pain. I'm dizzy and nitro makes you more dizzy. You must be one of those ambulance drivers that didn't get 50 years of BLS experience first. So, no I didn't take any nitro." :wink: Lungs are clear b/l with good air entry. Sat is 98% on room air. Blood sugar is 152. BP 102/64, P 92, RR 16 unlabored. Since she is at 98% already, we will put her on 6L NC unless someone objects. Your partner has set up the monitor and wants to know if you would like him to attach it to the patient.

You are called to the residence of a 69 year old woman who is feeling weak and dizzy. This has been getting progressivley worse over the past 2 days. She has a PMH of CAD, CHF and DM. She is on ASA, Lasix, Kdur, Digoxin, ntg prn. No allergies. What else do you want to know?

Don't really see a choice here. The guy has a pulse. It would be different if he was still in PEA. Technically he is no longer dead and therefore should be cared for. The outcome is going to suck, but what can you do.

Without hearing what the tapes say, it is hard to place blame (should there even be blame?). If I was a cop and I heard that there was a guy with a gun (unconscious or not) my weapon would be drawn until the gun on the scene was secure. Then I would worry about first aid stuff. The dispatcher and dispatch info is only as good as the caller on the phone.

Here are some interesting tattoos for you.

Always listen to the doctor (ask your mother, she'll tell you the same thing). When I'm not around, listen to Dust.

I respectfully have to disagree with you, Dust. AAA is much more common. Here are some stats from emedicine: Frequency: In the US: Ruptured AAA is the 13th-leading cause of death in the US, causing an estimated 15,000 deaths per year. The incidence of AAA is 2-4% in the adult population, and 11% of cases in that subset occur in males older than 65 years. Despite increased survival following diagnosis, incidence and crude mortality seem to be increasing. Frequency: In the US: CES is uncommon, both atraumatically as well as traumatically. It is often reported as a case report due to its rare presentation I think AAA needs to be high on your differential in a case like this. I think this case also shows the value of a good history and physical. Lower back pain with numbness in the legs can occur from both AAA and CES. AAAs will not give you incontinence and usually will not cause motor function problems. A good history is the best medicine, the devil is in the details.