triemal04

Guess she probably means "toprol." So it's potentially a beta-blocker OD. Call, or have her call, her pharmacy, confirm what the pills were, when her prescription was filled last, and with how many pills. And see if she's taking anything else. Find out if there's anyway that something else could have gotten into the pills other than the kid, and why she thinks it was the kid in the first place. Real beta-blocker OD's, especially with extended release pills are no joke. If that's what this is, while the kid is currently fine, bad things may happen. This kid needs to be in a PICU, preferably in a hospital with a good toxicologist. Start working on making that happen. While that's going on, place kid on monitor, continously monitor the heartrate and BP, start 2 lines, and since you happen to have a niftly little istat run the chem8 cartridge. At one hour and no signs of problems it'd be worth considering activated charcoal. For a 1 year old this will require a NG tube and probably some sedation. I'd get this ready but I'd like a little more confirmation that there was an ingestion before I started the procedure. Have large doses a glucagon and an epi drip ready to support the BP. If you are really in a high-speed austere environment you could do a lipid infusion...but that's a bit outside my area of expertise. Probably need to wait until the kids reaches the PICU.

Type and number of pills and what is the estimated time of ingestion.

Highly doubt there was any indication that made flying the kids neccasary. While it's hard to be completely sure without actually being there and doing my own assessment, seeing what actually happened and knowing the area, I would be shocked if there was anything going on that really neccesitated a flight. If you watch the video it looks like the mom indicates that the shelf was actually a large bookcase; depending on what was on it there definetly could have been a lot of force involved...or there might not have been. Either way, a real assessment should have given enough info to make an informed decision. As far as "seeing the skull"...the video shows one kid with a bandage on her forehead. Not like there's a lot of tissue over the bone there, especially in a 3 year old so it wouldn't exactly be shocking that a cut that required stitches exposed the skull. Poor call all around.

That's nice V. And I don't disagree that it is innapropriate to post certain information, especially identifying information about the people we treat. While it would be very hard, if not impossible, for anyone to identify this lady (other than herself) I do think that it was a very dumb thing to do, and not right. Turns out this was the guy (if anyone remembers) that made a splash this spring for doing a lot of crap like this. When all of that came to light is when the picture of the lady in the wheelchair (and a lot of others) was posted by the news media (and I'd have to guess when she realized it was out there). So...I do have to ask again...think she'll sue the XXX news for displaying that picture? Bottom line: be smart when using social media and the internet. If you aren't it can and will come back and bite you on the ass.

Really, like what? While the patient may have been able to realize who it was from looking at a photo of the back of her head, it's not likely that a random person would be able to identify the subject; without the quote it's actually hard to say for certain if the subject is a male or female. I also don't see anything that would indicate where or when this picture was taken. Why? Why does the fact that an oxygen bottle is present (and in use) matter? And really, that does not look like a hospital gown so much as it does a dress, or shirt. Granted, in this day and age people really ought to be using a bit more common sense when it comes to social media, especially since the courts have consistently sided with employers who discipline (ie fire) employees who act like morons on facebook or twitter. Also have to wonder if the lady in question will sue the New York Daily News...you know...since they posted the same photo...

Holy hell! Immediately back away from the patient and take cover. Request code 3 cover from the police and be ready to defend yourself it you get attacked. Shady looking chickens are no joke...dangerous little beasts...

Interesting. Was that the actual diagnosis, and did they run any other labs, and hopefully an ABG? From what you gave it almost seems like it could go either way.

At this point you have placed a 20g PIV in the AC, given 0.8mg of narcan IVP, 2000ml of normal saline, and are assisting the patient's respirations with a BVM. You have a dopamine drip running at 5mcg/kg/min. Your vitals are now: GCS-8 (2/2/4) p-144 with PAC's, BP-70/32, rr-8 spontaneous/shallow, 12 assisted, SpO2-still unknown, ETCO2-34mmHg with a normal waveform. The patient only will withdraw to deep painful stimuli and is incoherent, only responsive for very brief periods after the stimuli. You are now 40 minutes away from the level 3 trauma/community hospital. What next? Couple questions: Is dopamine really the best choice for this particular patient? At the requested rate the vast majority of the effects will be on the heart rate and strength of contraction. Phenylepherine isn't an option, but there are other pressors out there. Are you going to continue the fluids or stop at 2L? Any other tests that would be appropriate for this patient? If you do decide to RSI this patient, how will you counteract the hypotension? How much sedation (and using what med) do you think would be needed for someone this sick and hypotensive?

Nasty. Probaby sepsis and DKA. Whether or not this is what precipitated the arrest or there was a primary cardiac cause is still debatable. If the infection has reached the heart and is causing something like myocarditis that would help explain it. However... 1L bolus of fluid on top of the 500ml No antiarrhythmics. 5mg of versed for seizure control (and sedation after the fact) would seem appropriate. With the rate dropping on it's own no need for rate control. A chem7 or chem12, cbc, cardiac panel and lactate are needed (and partially done). If you carry them it would be good to start antibiotics (cipro would probably be ok) and if possible (doubt it) draw cultures first. No cooling. Continue with the previous treatements and settings. Sick dude.

Everything else can be done during the transport, so may as well start. Hook up a vent, 8ml/kg, PEEP-5, FiO2-1 (titrate that down as possible), AC with a rate of 12. Lungs were clear and equal, right? Give 500ml and then tko the lines for now, but be ready to support the BP with fluids and pressors if the BP drops as the epi wears off. Place a probe to get a core body temp. The 12lead is interesting. Those look a lot like flutter waves, and as best I can tell it's actually right at 150 (give or take a beat) which is very common with new aflutter. It does look there are the start of dewinter waves in the anterior leads and elevation in AVR, so a MI is also very possible, and would make sense given the situation. Full assessment of the body and clothes; strip as needed. Any deformities, discolorations, abnormalities? Signs of dehydration? Trauma? Pacemaker/defib in the chest? Check the infected foot too. Anything in the clothes? Are they wet? Discolored? Any response to heavy painful stimuli? If so check each extremity to see if you get a response from all of them. What was the guy actually doing in the field? Fertilizing? Spraying? Any chance of a toxic exposure, or just general farm work? Does he have a preexisting eye condition? Looks more like sudden vf due to a MI. May have an underlying infectious problem (ie sepsis) or undiagnosed diabetes. The pupil is concerning, but at this point there's nothing to be done, so just watch for any signs of herniation. Monitor and reassess every 5-10 minutes (vitals, respiratory effort, 12lead, and responce to stimuli). If the heartrate stays that elevated for a long enough period of time that the epi would have worn off might start thinking about either cardizem or metoprolol if the BP is still normal.

What is the setting where the 2 units are stopped? Is it in a turnout or other area where there is room to SAFELY operate outside the vehicles? (preferably shielded by the 2 rigs) If so, remove the patient and work the arrest outside. This will allow all 4 set's of hands (or at least 3 if you keep 1 person as a spotter for oncoming traffic) to work the resuscitation. If not and you have a larger ambulance, transfer the patient to your gurney and move to your rig for the same reasons. If that is the case, shock the patient (with your monitor to minimize hands off time) then take over compressions while your gurney is prepped. Switch rigs as quickly as possible, and then start a full resuscitation; IV access with a 500ml bolus to start, intubation (without interrupting compressions) followed by waveform capnography, epinephrine, the antiarrhythmic of your choice, and more CPR. Basically, start a standard CPR. The seizure was most likely a vf seizure, but not neccasarily. Take a look at the foot and the rest of the body for any discoloration or abnormalities. He was working in the field, so...what's the ambient temp like? How long had he been working? Known meds? Allergies? (both environmental and to meds) Lung sounds? That'll do for a start. If you truly can't move the patient and really can only fit 2 people in the back then you're pretty much screwed if the patient stays in cardiac arrest. Defibrillate the patient, trade out the first EMT for the driver and secure the airway ASAP. If it's really that cramped intubation may not be possible, so use a SGA if you have to. (having some type of advanced airway in place will make it much easier to ventilate the patient in a cramped setting and if someone can reach through from the front to work the BVM it'll be so much better) You'll have to manage the BVM in between starting a line (go for the EJ), switching monitors, pushing meds, etc etc. Not the best situation, but not the end of the world. Swap the person on compression every 2 minutes and go with what was done in the second paragraph.

Currently: temp- 37.4C on her forehead, extremities are still cool, core is still warm. ecg- sinus tach with PAC's and diffuse ST depression, no change except an increase in the number of PAC's. Pupils still 4mm, midline and reactive. Pt is not able to follow commands anymore, withdraws all extremities in response to pain. Deep tendon reflexes intact. Pt is not alert enough for a full cranial nerve assessment, gross neuro's seem to be intact.

So you have now been enroute to the nearest hospital (level 3 trauma/community hospital) by ground for 10 minutes with a 50 minutes remaining. For those who requested this, why this method of transport, and why this hospital versus the other two? For this scenario we'll say that any change in your destination at this point will add a further 20 minutes to your transport time. At this point you have placed a 20g PIV in the AC, given 0.8mg of narcan IVP, 1500ml of normal saline (with 500ml more still running), and are assisting the patient's respirations with a BVM. Your vitals are now: GCS-9 (2/3/4) p-124 with PAC's, BP-66/30, rr-10 spontaneous/shallow, 12 assisted, SpO2-still unknown, ETCO2-34mmHg with a normal waveform. The patient only responds to deep painful stimuli for brief periods and does not respond appropriately to questioning. Any further tests or treatements anyone would like? If I didn't mention it before the patient is an average appearing early 50's female, about 150 pounds in weight. Edit: and if you aren't sure what I meant by "routinely carried"...just ask. It'll be a judgment call anyway.

Oh please please please tell me that was a real conversation!

I meant do you specifically suspect that this patient as presented could be under the effects of something like a speedball (mixed depressant and stimulant), and if so, why? I'm just curious, that's all. And personally I'd say that EVERY paramedic should be concerned with what happens to the every patient after the reach the hospital, especially as our care can affect that. Edit: get to the rest when I have more time today.

That will vary from area to area, though everywhere requires that you drive with "due regard" even with lights and a siren going. Personally, if I'm temporarily stuck in a line of cars I see no point in blasting my siren to get people to move...when they can't. So no reason to use that, though the lights stay on. And depending on where you work there are many, many, many manymanymanymany places where traffic can be bad enough that you really do need the lights on to reach your destination in anything approaching a timely manner.

If this was a polypharm OD with a stimulant mixed in (like a speedball) then that is a concern. With what you've seen, in your judgement is that something that you're terribly worried about ? (honest question) If this was a polypharm with other depressants the bigger concern would be that if you had to take over her airway you'd just removed the ability to keep her sedated with narcs (for at least awhile). Regardless after the second dose of narcan there is no change in her mental status or her pupil size.

For those of you advocating driving emergently to this call based on anecdotal personal experience, do you also think we should be going emergent to ALL calls, or all calls that you have gotten the wrong information for at some point in your career and should have had a different response mode? Based on the given patient information, what requires an emergent response and treatement? Everyone can point to calls that had nothing to do with what you were told by your dispatch, but unless you do think it's appropriate to drive emergently all the time, at some point you have to start listening to what the 911-caller says. (This ignores the fact that this was a 21-mile trip in an urban rush hour; if there truly was no closer unit available that actually would warrant the lights, though not any extra speed or anything other than routine driving.)

Why are you asking?

The boyfriend gives you a 4-week pill minder that is still mostly full, is unable to find the actual prescription bottles. Further history from the boyfriend is unavailable, just repeats that she was "sick" and has blood sugar and pain problems. The patient now has an OPA in place with assisted ventialtion at 10/min, a 20g IV is placed with right AC (your partner says he couldn't find anything else in her arm) and a 1L bolus of normal saline is in progress. The general consensus seems to be for 0.4mg of narcan, so that is given IVP. After about 4 minutes you now have: GCS-11 (3/4/4) p-101, BP-70/36, rr-12/shallow, SpO2-still unable to obtain a waveform, and pupils 4mm and reactive to light. The patient is very lethargic will open her eyes and focus on you, but without constant stimulation (loud voice) is unresponsive. Her answers are very slow and she seems very confused.

There you go.

Do you have the ability to proceed at your own discretion, and/or confirm that your dispatch is correct about your protocols? If that's the case the case then confirm that they are (or aren't) right, and then proceed as you see fit. If you can't do that and are required to do what they tell you...how much trouble will you get it if you blatantly ignore them, and how much is your job worth to you? If ignoring them and driving normally is something that will get you in trouble...then absolutely, turn on your lights and sirens and go...but just because your lights are on doesn't mean that you need to be speeding and driving like a nut. If people decide to pull over for you...great. Drive on by...at the speed limit. If you only need to pause at intersections instead of coming to a full stop...great. Go on through...at a safe speed. You can be told to do almost anything by your dispatch and supervisors...but short of them riding with you, you have a huge amount of discretion in how strictly you do what you are told, versus meeting the letter of the law, so to speak. It's a two-edged sword, but in this situation it's beneficial. From the managements side, it's worth remembering that a lot of private companies are contracted to have a certain responce time and anything over that will lead to fines, and potentially them losing their contract with that particular location. It's very unfortunate, but this does play a part in how some companies determine the responce mode.

Let's have fun with this but keep it as realistic as possible. Feel free to ask for any medication, treatement, or assessment tool you want, with the caveat that 1) you need to actually know how to use/do/administer it without checking Google, and 2) it's routinely carried on a 911 ambulance (though there'll be exceptions for that). You are working on a primary 911 ambulance with a partner of the same skill level as you. Other than a helicopter there is no intercept with a higher level of care available. You are authorized by your medical control to perform any intervention/give any med that you feel is appropriate (as long as you follow the 2 rules above). You are currently working in an area that goes from urban to very rural, and are currently 60 minutes away from the nearest hospital by ground. A medic/RN helicopter with blood products and a few more advanced interventions/meds is available and will decrease your transport time by 20 minutes but will take 15 minutes to reach you. The first responders are minimally trained to the EMT level and there are as many available as you want. There is a Level 1 Trauma Center/Academic Hospital 75 minutes away, Level 3 Trauma Center/Stroke Center 70 minutes away, and a Level 3 Trauma Center/Community Hospital 60 minutes away. All have cath labs with interventional cardiologists, fully staffed ICU's, and are capable of at least general emergency surgery. You are dispatched for an unconscious female with the local fire department and arrive on scene as the same time as an engine company with 3 FF/EMT's. The house is generally rundown and unkempt with no apparent danger. You are met by an unhurried adult male who tell's you that "my girl isn't feeling good and I can't wake her up." He leads you down a long narrow hall filled with junk to a back bedroom. Upon entering you see a adult (early 50's by appearance) female laying in bed not moving. Go.

Honestly, if your company is so cheap (there's another term for it, but I won't use that one) as to only cover "emergency care" while you're located in essentially a third-world country then you shouldn't feel bad about doing whatever it takes to turn your "non-emergent" problem that is a risk of your employment (those long, long flights) into an "emergency." "Hey boss/medical gatekeeper/asshole, I just flew in and now I've got this severe calf pain, swelling, and some discoloration in my calf. Oh yeah...and I'm having trouble breathing." Sounds like an emergency to me... As an aside, I remember you bringing this up and saying that you take aspirin before a flight. When you're next back in the states it might be worth seeing your PCP and bringing up this situation and the reality of your employment situation. Don't know if they'd be willing to give you a scrip for lovenox to take prior to the flight, but it'd be worth looking into.