ERDoc

I hope the police are investigating, because there is something fishy going on here.

Stick a fork in him. He's done.

This again goes back to pt capacity and it sounds like you did all the right things Dwayne. I hate to say, but sometimes, even the doctors don't get it, especially in circumstances where they don't have a lot of experience. Beiber brings up another point. The police could have been involved. "Hey Nurse Asshat, I'm calling the police down here to explain to you and the family what kidnapping, assault and battery are." Once it involves a police car sitting outside their facility they are usually pretty understanding. A little different but a story from a few years ago that involves one of my PAs who also happens to be police auxillary. NH sends a pt to the hospital for whatever reason, is worked up and discharged. The pt is A&O/has capacity/etc. The pt is sent back by EMS but NH refuses to let pt in stating that they don't feel the pt should have been discharged. Puts up a big stink. The PA politely calls the charge nurse (this was at 1am) and explains that they can't refuse as the pt has paid for the bed/room and has no reason to be refused. They still refuse to let EMS bring the pt in. After a call to the state troopers, two units show up at the front doors and explain the situation and that if the pt is still refused allowed back in to his place of residence, they will be more than happy to arrest the charge nurse. With a smile on her face, she let the pt back into his room.

Open laparotomy and transport.

Awesome job Mike. This is a great case of thinking about normal and abnormal anatomy. You had to think outside the box to figure it out. Luckily I had the CT scan so I didn't have to. The guy had an umbilical hernia and the free air was slipping out through the small defect in the abd wall and tracking up. Mike gets my nomination for provider of the year and Arctic gets runner up for keeping his differential consistently broad.

It was a routine colonoscopy as the pt has a strong family history of colon cancer (and pericarditis). He does not personally have any lesions. No other surgical history so no scaring at the belly button but you are getting close.

All very good thoughts but they would lead to pneumomediastinum. Some how the air is leaving the intracavitary space and becoming subq. We know the source is in the abdomen but how is it getting from the intraabdomenal space and going subq? Looking at the pt, it starts at the level of the belly button and goes as high as the jaw. There is no subq air below the umbilicus.

You are correct Mike. The guy had a perf resulting in pneumoperitoneum. Now, can you explain how he developed subq emphysema that made it's way all the way up to his neck? He has no pneumothorax or pneumomediastinum.

Here is your chest xray

Despite 1C's best attempts to bury our pt before he has dies, we get him to the hospital. What kind of testing are we going to do? What is our working differential (besides pericarditis)?

Mike, you need to stop thinking like a cop and to start thinking like an EMS provider. We are not law enforcement officers and do not have the same rights/responsibilities that LEOs do. A doctor's order is not a legal order and no one is obligated to follow it. You are under no obligation to follow the SNF physician's order. The only one you have to follow is your medical director/medical control as it is their license that you are operating under. If the pt has a court order to be evaluated, that is a legally binding order. However, it is a legal order and an the only ones that must abide by it are LEOs. Once they contact you to transport, your duty to act goes in to effect. Just because the pt tried to hurt himself 2 day ago does not mean that he is looking to hurt himself today. You cannot force him to go based on this.

But how is the air able to cross the diaphragm into the chest? If the abdomenal and thoracic cavities have not been violated other than the perfed colon, how do the air go subq? Would it not be contained in the cavities by the muscular walls?

A definite possibility. How would you explain an intraabdomenal perf leading to subq emphysema up to the neck? How would the air be forced into the mediastinum? He was sitting at home, watching TV at the onset He was discharged about 5 hours prior to the onset Records from the procedure are not available He has a Cheeseburger and fried from McDs on the way home

No history of trauma. Subq air from umbillicus up to mandible. No signs of trauma. Psych issues under control and he is compliant with is meds (seroquil, ativan). Lungs are clear bilat. Heart has normal s1s2, no murmurs, rubs or gallops. The pt does not believe there were any problems with the colonoscopy. He wasn't told of any and went home as scheduled. He thinks they removed a few polyps but isn't sure. No rectal bleeding. No BMs since.

Thank you. Started 3 hours ago and has gotten worse. Pain is a sharp pain throughout the entire chest that increases with deep breaths. No shortness of breath. Upper abd pain is described as sharp, nonradiating and worse in the LUQ. Only past medical history is bipolar/schizophrenia and a colonoscopy this morning. No allergies and only meds are psych meds.

Not to mention, the courts have said that people can refuse dialysis as well as many other life prolonging treatments. There is plenty of presidence in the US for stopping dialysis.

All treatments are done with no change. He says he enjoys you playing with his subq air and gives you an awkward smile. Temp 37.6 rectally (yes, you are that good). No history of blebs. No blood thinners, just anti-psych meds.

No resp distress or complaints of trouble breathing. His neck does appear symetrically swollen. When you palpate the neck you can feel subq emphysema. Maybe, maybe not. Thanks for playing. HR 108 RR 16 BP 142/88 93% on room air No JVD No edema Has a hx of bipolar and schizophrenia Pulses/BPs equal bilat EKG sinus tach with a rate of 110 with nothing abnormal

You are called to the residence of a 57y/o male. The patient tells you he has had progressively worsening chest pain over the lat 3 hours. It increases with a deep breath. He also has upper abd pain, more in the LUQ. The pt denies any sob. His son, who arrived home from college and found his father this way and called 911, tells you that his father's neck looks "bigger than normal". Take it away.

Hey Bushy, I think you are in he wrong thread.

Just to go a little tangential to this discussion, I just want to get on my soapbox about when you do have to hold people against their will as well as the people who are drunk/high. It really pisses me off when I see people getting confrontational with these people as their first line of treatment. When someone tells you they don't want to go (and they have to because they lack capacity), your first response shouldn't be, "If you don't, I'm going to tie you down and sedate you." I see it all of the time, even in the hospital. Unfortunately it is from the less experienced people, many of whom have EMS experience. You don't get anywhere by poking the bear. It only makes the situation worse. There are times when you will have no choice but to restrain someone but that should be a last resort. For me, I avoid it like the plague because of the mounds of extra paperwork, ER resources required, legal risk and risk to the staff to restrain and/or sedate someone. Your first course of action should be attempting to calm them down and talk with them. I try to explain calmly and rationally why they can't leave or why they can't sign AMA. "I understand you want to leave, but unfortunately when you try to hurt yourself there is a legal process in place that you have set off. We have steps that we have to go through and how easily or quickly those steps happen is up to you. If you are calm, quite and cooperate it will go a lot easier and quicker for you. It's not up to me how this visit goes, it's up to you." EDIT: Forgot to finish my thoughts. In the ER, my main goal is to get people out of the ER. If I have to sedate someone, it makes it take a lot longer until I can get them out so I try to avoid chemicals at all costs. Some psych facilities in the are require the pt to be out of restraints for 2 hours before they will accept them so if I can talk them down and avoid poking the bear I can get the to where they need to be a lot quicker. A lot of times all it takes is the lights off, TV on and food in front of them and most people will calm down.

Let's not be too rough on Mike. The legal side of medicine is something that is very poorly covered in EMT/paramedic class as well as medical school. Let's make it a learning experience for everyone. Here in Michigan, a person has to app and certed, meaning that someone has to apply to have them committed and a physician has to certify that they need to be confined against their will. This comes after EMS has brought them to the ER. Before the paperwork is complete EMS/PD/ER have the ability to hold someone against their will if they are a danger to themselves or others or lack the capacity to make their own decisions.

Don't feel bad Beirber, you are pretty much correct. The facility doctor is not YOUR doctor. The only ones you have to follow are your medical director and your medical control. This pt is not a psych pt, whatever that means. You have to assess his situation now. If you can determine that he is not suicidal, homicidal and has the capacity to make his own decision (yes, EMS can do that, it does not take any special degree) then you cannot make him go. The only exception is if there is already a bluepaper, app and cert, 5150 or whatever your local jurisdiction has. If that is in effect then someone else has already determined that the pt lacks the capacity/is dangerous to someone and you cannot override that. If the NH doctor was so concerned he should fill out the proper paperwork and then you can force pt to go.

This would have been a lot easier 2 days go. At that point he lost his right to refuse. Two days later it is a different story. If you decide that he is not homicidal or suicidal and has the capacity to make his own decisions, then you cannot make him go. You can do your best to convince him, but it is ultimately up to him. POAs have no power until the pt loses his capacity. The NH physician has no authority over you, so his order is irrelevant. Maybe the nurse can drive him on her way home.

Rich, SCPD is also doing a pilot program with sector cars carrying IN narcan with several saves so far.