ERDoc

So, what is wrong with hyperventilating the pt and then getting him out? If you oxygenate appropriately you should be able to get down a flight of stairs. It takes most people to get a tube in than it does to walk down the stairs. Get him in the ambulance and then give him the narcan. You have just saved your pt from the risks that go along with being intubated (including improper tube placement and death). In some hospitals you may have saved the pt an ICU visit and the taxpayers from paying for it. I recently had a guy come in who OD'd on valium and had minimal respirations. Hit him with some flumazenil. The first dose didn't do much so we hit him with the second dose. He finally starts coming around just as the nurse is putting in the foley. Good morning sunshine.

No h/o trauma. Considers a walk in clinic to be his family doctor, hasn't been there in about 1 year. No h/o mumps. 1. None of the above 2. Never had pain like this before. This pain is not excruciating, just more of a dull ache. 3. Feels a little nauseous, but not enough to stop him from eating a bag of chips in the waiting room. 4. Has chills but has not checked his temp. Do you want to check one? 5. No dysuria, hematuria or discharge. 6. Has not had any of these symptoms but has not had sex since the pain started. Do you want to have sex with him to find out? (OK, that may be a little overboard, but I commend your dedication to pt care)

OK, that's pretty funny. No trauma. He just kinda noticed the pain earlier in the day and it has been getting worse. He has not been drinking or doing drugs. He also has been c/o some chills for the last hour. He's never had anything like it before. What else do you want to know?

Look up Cullen's and Turner's signs for a few examples. But, I am not saying these are the correct answer.

She's not sure. Her doctor gave her the prescription.

Good question. There are medical problem that can cause skin changes over the abd, but I'll let you guys look that up for now.

You are called to a farm in a very rural area for a 26y/o hispanic male with b/l testicular pain. It is 2330 and he states the pain started around 1500 and has gotten progressively worse. Let the fun begin.

The pain gets worse with any movement, cough and deep breath. No surgical hx. No problems with BMs or urinating. He eats a normal diet. Vomit was greenish in color. Pain does not radiate. No noticable skin changes. No history of trauma. Last meal was at 1800 and she is afebrile.

This first rule of medicine is that nothing is absolute. You can give nitro at any BP, but should you is another question. There is no hard and fast rule that says what the limit is for ntg. In the field your protocols will dictate at what point you have to stop. There is no enough info given to say what is going on. CHF is in the differential. Not every pt reads the textbook and pts with CHF can be hyper, hypo or normotensive. It all depends on multiple factors including heart condition, resp status, anxiety, etc.

You can always give more narcan. Keep him alive enough to get him to the ER and we can start him on a narcan drip.

Vytorin=ezetimibe and simvastatin Augmentin=amoxicillin and clavulinic acid prevacid=lansoprazole Sorry about the ethnocentrism there. Hope this clears it up. A&OX3, GCS=15, SES is middle class, average American woman. Weight about 200lbs (100 kg) There is no dyspnea, she speaks in full sentences. She does cough on occasion during the interaction. BP 140/86, RR 14, HR 70 SaO2 99% on RA. Cough was productive but it has been getting less since she started the abx. It was green but is now more yellow. Lungs show good air entry with scattered rhonchi. EKG shows NSR with no ST or Twave changes. She takes every dose of the augmentin with food and hasn't had any problems for the past week. No herbal stuff and she has not had any other meds since the pain woke her up. The pain was not generalized. It covers the RUQ and the upper portion of the RLQ. It has not changed location at all. She describes it as an on and off burning sensation. She vomitted once prior to your arrival. Last BM was about 8 hours ago and was normal. On exam the LUQ and LLQ are nontender. The RUQ and upper half of the RLQ are very tender even with light palpation. It is difficult to assess for rebound due to the pt's discomfort. BS are normoactive.

60y/o female c/o right sided abd pain. It is 0100 and she states the pain woke her up at 2300. When she went to bed at 2000 she was fine. PMH is significant for elevated cholesterol for which she takes vytorin. She is also on ASA and prevacid. No allergies. No h/o surgeries. She states she was dx with pneumonia a week ago and is currently on augmentin. What else do you want to know? What is your differential?

Wouldn't want to give it to someone with a disection or aneurysm either. Nitro to either of these pts might not be bad (assuming we don't get a reflex tachycardia) but ASA is a no-no. You CANNOT base your treatment on any EKG alone without a clinical story.

Never say that when someone has been intubated. Intubation, while a very common procedure, has many pitfalls and should not be taken lightly. Giving narcan might have been a better way to go, though I'm playing Monday morning quarterback and wasn't actually there. Another option would have been to preoxygenate, get him down the stairs and then give him the narcan.

I think it is a procedure that is making a comeback. I am not far out of residency and we were taught how to do them. I did a few during residency, but have not had the chance to do any since. I don't know what the reluctance would be to do one.

BOW BEFORE MY SUPERIORITY!!!! FOR I AM THE ERDOC!!!! :twisted:

ACLS is more than just cardiac arrests. I agree that in the standard case, TVP is not indicated but you always have those cases that don't fit the textbook mold. I once had this guy with a pacemaker that decided it didn't want to work properly. He was 100% dependent and every couple of minutes it would stop working, for a few minutes. So, in essence this guy was in asystole and therefore in cardiac arrest. Best thing to do is drop a TVP in. We did it and the guy was fine after that. I'm not saying you are wrong, I'm just nit-picking for the fun of it . A TVP really doesn't take that long to put in. It takes about 5 min tops to get the cordis catheter in and then another 5 to get the pacer in the right spot. To be honest, cardiologists are not as good at them as ER docs are. We put in way more cordis catheters than they do so we get more practice. That being said, could I successfully put in a balloon pump? Not likely.

NSR with some J point elevation. :wink: GI cocktail and go home.

Initiation of transvenous pacing?

Hey. Watch it there fella. I do have to admit though, watching new interns during ACLS or a real code is kinda fun. You have to remember though, ACLS/running codes is a skill and if you don't use it, you lose it. Outside of the critical care world (anesthesia, ICU and best of all EM) how often do docs really run codes? When was the last time your neurologist, orthopod, family doctor ran a code? One of the best stories I have from residency happened in the ICU. It was August of our intern year. We had a pt who started seizing. The medicine intern who was taking care of the pt runs out of the room and yells, "This guy is seizing, we need the ER resident!" Made me feel good though.

Here is the Garcia book. As for anatomy and physiology, look for stuff from Board Review Series or High Yield. These are aimed more at medical students, but have a great deal of info. Have you tried Half.com to look for the books you will be using?

I would recommend getting the textbook that you will be using in class and starting ahead of time. It might not be a bad idea to get ahead on some of the tougher things like cardiology and pharm. As many have said in the past get Dubins and then move on to Garcia for EKG.

The reason to remove it is because it has a very real potential to become an airway obstruction. You're better off to remove the danger and then use simple first aide techniques such as pressure. You are not likely to cause any more tissue injury since you are pulling it out the same way it went in. The damage has already been done. Please don't comment on something if you don't know the right answer since something simple like this will not need a maxillofacial surgeon. MFS would be the wrong service any way, you are more likely to call a plastic surgeon. Something as simple as a through and through lip or cheek injury does not require a specialist. It is generally a simple 3 layer closure done by the ER doc, tetanus, maybe antibiotics and out the door.

I agree with you Rid. This is one of those questions that comes right from the textbook, almost word for word. It is a classic question that has been taught for years and years. The only impaled object you remove in the field is one in the cheek. There is not much to debate here. Any EMT book will tell you the same thing. Like you said, take it out and put some pressure on it.