ERDoc

Just out of curiosity, it is difficult to get an EMS job in other parts of the country? Here all you need is a pulse and a card (the ink doesn't even have to be dry) and the pulse is negotiable.

My respect. That and 39 cents will buy you a postage stamp.

From the hospital standpoint, the only confounding variable here is the EtOH. If she presented the same wihtout the EtOH, the collar would come off and she would go home (assuming no other injuries obviously). EtOH gets a collar and xrays, and likely a CT (depending on the xrays).

We have a winner!!!! Yes, this woman has a malignant pericardial effusion causing tamponade. The previous syncopal episode was probably related to a pericardial effusion, but this time the effusion has become so severe as to cause tamponade physiology. Pts with cancer can get pericardial effusions. These effusions are usually chronic in nature, whereas in trauma they are acute. Tamponade in a trauma pt can be caused by as little as 100cc of fluid in the pericardium. With tamponade you can see what is called Beck's Triad which is a decreased pulse pressure, muffled heart sounds and JVD. What happens is that the fluid in the pericardium compresses the right ventricle to the point where it cannot fill up with blood. In this woman's case, as her pressure is dropping, despite getting 4 liters of fluid and started on Dopa, we were at a loss to explain why she was crashing. When I first saw her I was thinking dehydration also. As a last ditch thing we put the ultrasound on her and found nothing in her belly, so we took a look at her heart and saw a huge effusion. Performed a pericardiocentesis and got about 500cc of fluid out :shock:. As the fluid was being drained, she starts telling us that she is feeling better. Her pressure starts coming up and stabilizes at 140/72. The cardiologists come by and do an echo on her and she still has a moderate effusion with some evidence of tamponade. This was a tough case, even for us. Looking back on it, the diagnosis was staring us right in the face. When she presented she had a pulse pressure of about 12 with muffled heart sounds. When we put the EJ in she had huge EJs, not what you would expect in someone with dehydration. She had a classic Becks Triad but it wasn't picked up on. Obviously in the field there is no ultrasound, so it would be more difficult to make the dx. Like I said, tough case. You guys gave some really good answers.

Pt is crashing, you're not going to get a CT. The EJ are engorged supine and upright. Pressors help bring the pressure up, but only momentarily. Her heart rate is now sky high. Pt is still conscious and maintaining her own airway, no need to tube. The labs will be of little use. Heart sounds are very muffled. Lung sounds are clear still. Pt does not report any problems with urination.

There was nothing impressive about the color of the vomit (no blood etc). What makes you think esophageal varcies? The 12 lead is unremarkable. All the labs previously requested were unimpressive. No fever. Your pts BP is now down to about 50/42 HR still in the 150s. Obviously at this point there will be no pedal pulses. You use your US again and there is still no AAA. Come on folks, your pt is crashing before you. As a hint, no matter how much fluid you dump in, the BP will not improve. Let's recap some of the pertinent findings: Pt with cancer Not feeling well Hypotensive (look at the BP again) and getting worse BP not responding to fluids EJs look like a CFR could hit them blind folded Lungs clear EKG nl Not septic or febrile Any more thoughts?

Not to be politically incorrect either, but in some circles the syndrome you have referred to is called Aye-tach, very unsimilar to v-tach (which is life threatening). My guess in this case is conversion disorder vs. malingering. What feild of work is the pt in?

No diuretics. Afebrile. Lungs are clear.

Abd is soft, not distended, nontender. Your state of the art dept has an ultrasound machine and you look at the aorta and it looks normal. You cannot find anything in the arms or legs, but the EJs are like pipes and you have no problem dropping in an 18. You give her 2 more liters and the pressure stays the same. What else are you thinking?

She is full code. Last chemo was 3 weeks ago, no radiation yet. Labs were normal when she was d/c last week. The only access you are able to get is a 22 in the back of the right arm. Fluids are going and after 2L her pressure is 90/80 with a HR of 140s (STach). You put her supine and she is now complaining of some very mild pain in the epigastric area going to her back and lower chest. She also gets that gray look to her face (the more seasoned know that gray around the gills, I'm going to die soon look). She is still conscious, but more somnolent.

A 59 y/o woman with a history of lung ca with mets to the brain calls you because of a near syncopal episode. One week ago she was admitted to the hospital for 2 days secondary to a syncopal episode. For the last two days she has not been feeling well, has had a few episodes of vomitting and some diarrhea. She is not complaining of any pain at the moment. Her VS are: 118 86/77 18 97% on RA. What else do you want to know and what do you want to do for her?

Heard a hospital presentation where the pt was complaining of general malasia. I guess her Cambodia was acting up again.

We once had the ME lecture to us about crime scenes and pts that come from them. He said that we should never try to identify which is which, as posted before it may hurt the case if there is conflicting info. He said just describe the wound (ie a 2 inch hole in the right side of the head). It should not change your management. If you add up the number of holes, it should be an even number, or else there is still a bullet inside.

:shock: DIDN"T COMPLAIN OF ANYTHING!!!!???? :shock: OK Rid, what't the story on that one?

Makes more sense. As a former EMT, I would not question you for anything you did. Just because you called an ambulance does not mean you don't treat the pt. I think it would be malpractice not to (especially if they had a 20 minute response time). They pt is yours until they arrive on scene, so you do what your orders/physicians dictate. Would you not do CPR on someone in cardiac arrest because you called the ambulance? I think that crews needs to check the attitudes.

Was the pt a dialysis pt?

A pt with a tension pneumo will have tracheal deviation (amongst many other bed signs). You MUST recognise this in the field or your pt will die. Obviously this depends on how rapidly the pressure in the cavity builds up, but if it has gotten to this point they need a needle in their chest. A spontaneous pneumo does not have to become a tension pneumo, but depending on how large the pneumo is you may or may not be able to pick it up. You would be surprised how many trauma pts come in with a small ptx. Most times there is nothing that needs to be done except give oxygen and recheck the xray a few hours later. Most spontaneous ptx are large enough to require a chest tube or pig tail, but do not produce a tension ptx. Pts with spontaneous ptx are tall, thin, white smokers with a sudden onset of sob and/or chest pain. They will generally be tachypneic. Their sats will usually not be abnormal. Their LS will be decreased on the affected side and if you percuss the chest it will be tympanic.

What exactly are you questioning? PS I had a pt come in yesterday with a FS of 11 and was still partially mentating (is that a word?). Got a call from the lab 2 hours later, "We have a critical value. Her glucose was 13." Yeah, thanks, we'll get on that right away. Thanks for the rapid notification.

How about a good H&P before we jump to ddx (it could be limitless). I throw in Fourniers Gangrene.

Ask this question to 100 people here and you will get 150 opinions. In the end, all that really matters is, do you consider this cheating?

Hypertonic saline is generally 3% (though other concentrations do exist), compared to 0.9% for NS. Giving too much can do very bad things. If you increase the osmolarity in the blood too high, you draw fluid out of the brain space, causing major shrinkage (JK), but you do get a major fluid shift out of the brain that can lead to seizures. As someone else said, if you correct hyponatremia too quickly you can get central pontine myelinolysis (bad). The only uses for hypertonic saline that I can think of would be to correct hyponatremia, but I can't see you doing this in the field since you will not be able to get a sodium level. In this case it is used as a slow drip. In seizures secondary to hyponatremia you give it as a bolus, but it is not like giving a NS bolus, give a liter and you could kill (bad, again) by the means I mentioned before. Unless you get some sort of method for checking sodium in the field, I really don't think there is much need for hypertonic saline.

The same questions that you ask someone with abd pain or chest can be asked of headaches. Do they radiate? Does anything make them better or worse? Is there a certain time of day when they occur?

Headaches require a great deal of history. Onset? Location? Quality? Previous headaches? Recent trauma? Visual disturbances? Photophobia? Hyperacusis? You can get more info out of a good, detailed hx than you will get from physical.

htn-hypertension hx-history fx-fracture tx-treatment (could also mean transport in some EMS circles) rx-meds, prescription r/o-rule out as in rule out MI cva-cerebrovascular accident (stroke) hr-heart rate bgl-blood glucose level As far as what the most common call/complaint it all depends on your pt population/location.

Here I am at 1:30am and the flight sim (yes, I'm a geek too) is still going even though I have to be at work at 8am. The person below me dreams of being president someday.