ERDoc

I was also asking if you have the cajones to make that decision, based on what you have.

Keep in mind that there are very few things that makes someone this tachycardic.

I'm not going to jump in here, but if you are calling it a STEMI, DO NOT wait for your enzymes. Time is tissue. Call the cath lab and get the pt going. For those that are calling this am MI, assume the pt has no contraindications and you have a communications failure and cannot contact medical control; are you going to make the decision to give lytics?

Whatever your mother told you was a lie.

You dated her too, huh?

What makes you think I'm joking?

Check out the scenario section. There are some pretty interesting cases that people have come across.

Personally, if I were on the scene I would break out my buff bag. I'd use the acetylene torch in my bag to cut the fence. Once I had her on the ground I would pull out my thoracotomy tray and crack her chest right there on the ground in the mud and rain (yeah, I'd go all Doug Ross on ER style). That's just me. If I took the call at medical control I would tell them to pronounce. I'm going to guess that since this is posted here there is some sort of twist to it. She was probably eating an apple, which she choked on. In an attempt to give herself the heimlich she slammed herself into the railing on the balcony. Getting nervous and overly aggresive she hits the railing too hard and goes over leading to her current predicament. The medics roll up and lift her off. They find the apple and pull it out. She then begins to breathe on her own. One of them puts his hand in her chest to thwart any bleeding that may be trying to take her life. Sorry about the ramblings, but it is 3am and has been a very busy Friday night.

I am a doctor and I don't get it. The best I could come up with was that maybe she was hypoxic and hypercarbic from resp depression. I was thinking that maybe the family heard carbon dioxide as carbon monoxide when the doctor was explaining what was going on. Just a thought.

Only if we get to cruise the beaches.

I jest, and don't call me Shirley.

Prinzmetal's is NOT the same as a cocaine induced MI. Prinzmetal is vasospasm of the coronary arteries. Cocaine does not do this.

Pleural effusion is a diagnosis on it's own. There are many reasons to have them; the ones you mentioned, a lung mass as well as many others. From your standpoint there is not much you need to know about an effusion other than it is there. The same is true in the ER. They are only clinically significant when they get to be big enough to cause resp distress, even then there is not much for you to do in the field. In the ER we can tap them if needed, but we generally don't. From an emergency standpoint it does not matter whether it is a transudate or exudate. I don't think you truly understand what gram positive means based on your post.

This is one of those topics that really gets me agitated. If your pt is in pain, you treat them. Spock, your surgeon needs to read sometime. It has been shown that pain is decreased by analgesia, but tenderness is not. This is a good thing because your pt will not be in pain and you will be able to better assess where they are hurting. To do anything else is cruel and inhumane. He is speaking like a true, old-school surgeon who has not kept up-to-date. Here are a few links you can pass along to him: http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum http://www.ncbi.nlm.nih.gov/entrez/query.f...t_uids=16953529 http://www.ncbi.nlm.nih.gov/entrez/query.f...st_uids=8959160 http://www.ncbi.nlm.nih.gov/entrez/query.f...t_uids=12517545 http://www.ncbi.nlm.nih.gov/entrez/query.f...t_uids=17032990 That is just a few and I think one is from the surgical literature. Of course most of the studies come from ERs. Where else do you see acute abd pain? The only reason you should ever withhold appropriate pain mediciation is when your pt's VS as unstable. Even then you have fentanyl (assuming your area allows it). AZCEP, you are right about narcotics leading to constipation, but giving them to someone with an acute abd will not be a problem. Even if they are obstructed they should not be in pain. The obstruction will soon be relieved once they are in the hospital. The problem I have is giving heavy duty stuff to pts with mild pain. There are a large number of docs in my area that automatically give 2mg dilaudid to anyone who walks in c/o pain, reguardless of where the pain is or how severe it is. It is no wonder we have such a drug seeking population in my area. No nurse where I trained in NY would have let an order like that go by without seriously questioning it.

How about with an obviously fractured ankle without distal pulses? There is really nothing to straighten, but the pt needs a reduction.

What kind of education were you given? Is it just the medics or also the EMTs?

I had a case last tonight that made me think of you guys (man, I have no life ). If you have a pt in the field with say an ankle fracture with vascular compromise, are you allowed to reduce it?

I used a short board once. We got our ambulance stuck in the sand on beach and it was the only thing we had for traction. Other than that it was used for collecting dust.

So you want to violate a person in order to make your job easier? I don't think it takes much for the nurse to hand the pt a gown and say, "Here, put this on. Open side to the back." But, I'm not a nurse so I will defer that to our resident nurses.

You absolutely DO NOT have to disrobe every pt. We don't disrobe every pt in the ER. It is purely situational. In the field you guys have to worry about things such as the environment that may make it not practical to disrobe a pt. I'll be damned if I am letting anyone rip my clothes off with half the town watching. Give it a try and I'll slap you with assault. In the scenario presented it is hard to say what would be appropriate since there is little info given. Even with a humerus fx you do not necesarily need to expose further. For any injury you can make an arguement that based on MOI there is for potential for X,Y and Z injuries, but you have to keep it practical and use clinical judgement/common sense (this usually comes with experience). I would have to disagree with the comments made about disrobing the lady with the headache. You are not going to gain anything from it. Why do you need to disrobe someone with pre-eclampsia? I think someone is just looking to get a few jollies. There is a tell tale sign that will let you know if a pt has eclampsia, we call it a seizure. You could justify disrobing a pt then, but I'm sure there are much more important things to do, such as stop the seizure. Just because a woman is pregnant does not mean she needs to be stripped. Pregnancy is demeaning enough for women with everything they have to go through. Why make it worse for no reason? Even in women with abd pain, why do you need to take off their pants? Can't you just unbotton their pants? Are you planning to do a pelvic exam in the ambulance?

Thanks for the link. I have to say that after reading over the paper, I'm not impressed. It looks like like some good prelim results for in-hospital arrests. For out of hospital arrests I don't think it will change anything. The results were dismal at best. These pts also need to go to a hospital with a cardiothoracic surgeon and cath lab. Not a pracitical idea for some of the more rural areas. Are we going to put cardiopulmonary bypass machines on the ambulances? In the field there is also the problem with an unwitnessed arrest. All of the pts in the study were witnessed arrests. I really don't see this changing out of hospital resuscitation.

Listening to the history I would be concerned for several other things. With the cardiac history I would think about pulm edema, pericardial effusion and a few other things. Reguardless of what the underlying problem was there was probably nothing you could do given how combative he was without being able to RSI

I did a quick pubmed search for the paper from UofC but couldn't find it. If anyone happens to come across it, post a link.

That depends on what you mean by "All blood work comes back normal." What things was she worked up for? Things that come to mind include MI, PE, anxiety among others. This does not sound like a seizure, more of a vasovagal reaction. You can get shaking with vasovagal syncope that can resemble a seizure.

This one is a tricky case. Like you guys I was thinking GB disease or something similar. The US and labs came back positive. With that much pain I did a CT and she had a rectus sheath hematoma (bleeding in the abd wall). Looking back on it now, she was pretty tender even with light indentation of the skin which would not be very consistent witrh an intraabdomenal cause. Turns out she ruptured one of her superficial arteries (inferior epigastric, I believe) with all of the coughing she was doing with her pneumonia. The ASA just made it worse. Good thoughts on everyones part though.