tcripp

Causes of metabolic acidosis include DKA and renal failure. Pretty much might not figure out the renal failure other than maybe my patient is in dialysis and I would have seen the shunts. Where was my "scene"? Did we do a d-stick? Did we look for a medic alert bracelet? You see, I took what you gave and made my decision from exactly just that (kind of what I thought you were asking). In reality, I would have done a more thorough exam to make my decisions. So, my questions to you: Are you inferring, then, that this patient is in DKA which I might have seen had we done a d-stick...or possibly would have determined with some type of medic alert bracelet indicating a diabetic patient? Are you trying to "pick a fight" with AHA on their suggestion for rescue breathing which is for the average patient? One thing I have learned is that medicine (including para-medicine) is not black or white. It's an art and many shades of grays. Frankly, depending on transport times / transport options (air vs. ground), it's possible I would not have RSI'd this patient but rather provided assistance. But, I think your point is on the rate and not the mechanism so I'll move on. Additionally, my training included that you did adjust the patient's breathing even if in DKA with kusmaul breathing. Now, maybe I slept and just totally missed out on that lecture so I plan to do a little extra reading on that one, but I simply do not remember being told to maintain a breathing rate of 30...

I'm assuming that I've (for whatever reason) decided to completely take over his breathing because he's hyperventilating with the potential to aspirate. So, I'd be dropping his breathing rate to 10-12 breaths per minute with an anticipated ETCO2 in the 35 area. BVM w/ O2. Is this the answer you are seeking?

I'm with Ruff - I'd like to hear your thoughts as well. But, for my two cents... I have an 11yo cousin. He's been diagnosed with the disorder. I've seen him both on his meds and off. He is very much more well "controlled" on them. If you ask him, he doesn't like them, but he takes them anyway. When he was first diagnosed, he was asked to simply color a picture. (He was much younger then.) The coloring job was less than stellar, even for his age. After the dosing (not sure if this was immediate or after some period of time...just after), well...the boy found the lines. The difference between the two pictures was amazing. Now, if you were to ask me if I thought that maybe too many were on the meds or if looking for a diagnosis is too easy when other options are out there, then I would have to say yes. My own daughter, at the age of 10/11, was suspected to be ADHD. The teacher at the time said that she fidgeted too much. So, we went the route of ruling out ADD/ADHD. Come to find out, the kid was just getting bored and the teacher was not challenging her enough. (We also had her tested at the local Sylvan office and she was testing at or above her grade level.) Hmmm. Maybe if our classrooms weren't so overloaded the teacher could have focused on her needs a bit more instead of looking for an easy out. But, that's another topic. Toni

Yes, Stayin' Alive is one. (And, cute Hutsy...) Another One Bites the Dust is another. Just be careful which one you choose to sing out loud in the little bathroom where your patient is wedged between the tub and toilet... AHA is now teaching "at least 100" which tells you better is more. But, if you are watching and you see the compressor going all SVT on the patient, slow them down. Let's give the patient the best care possible.

Interestingly enough, we ask for a SSN. However, it is usually in the privacy of our ambulance or even at the hospital. I've only had one or two reluctantly give it, but they did. The flip side? Every patient then gets a HIPAA notice letting them know that all the personal information they have shared will be kept confidential. What does it gain for me? Access to previous information already entered in to my computer such as medical history, medications and allergies. This included a semi-conscious patient (ROSC) and we needed to know about her hx/meds/allergies. Found her purse, found a SSN card, and got the information we needed. Yea! But, if the person has a difficult time telling me and would be more comfortable in typing it in to the computer himself, I have to troubles making the accommodation.

Unfortunately, I no longer have access to the ePCR, so any further I give you is what I can remember. Pt's wheezing was only on auscultation. His color was fine and he denied any difficulties in breathing. Now, as to the ANYTHING. Anything is possible. It was a dry, hot dusty day, so any allergens could have kicked it off. There were no leaks/smells from the vehicle. And, he's a retiree...he was on his way home from doing some shopping at a local butcher. Beyond that, I must admit that I didn't delve in as deeply as some would have liked. As with any learning, I bet I will do more so next time.

Appreciate your comments. Obviously, we don't determine if someone needs surgery (or a cath, MRI, etc) but we do get a feel for it and try to anticipate when a "harpoon" might be needed. Funny, for some of my hospitals, they really get put out if we haven't started a line with at least a lock. And, at times, I've been starting IVs in the ER...not just in the field. I did want to add to my statement, though, that in my consideration to DFib's query I don't believe I quantified my response. When I think of 'trauma', I am thinking of serious trauma and not the cut finger/stubbed toe scenarios. I was thinking more along the lines of roll overs,falls, projectile injuries, etc. It's on these that I think the potential for miscarriage (or other) is high. Also, I didn't want you to think I started an IV on just everybody.

Curious. Obviously dependent upon the patient, but do you not start a saline lock at the least for those who may need surgery...with or without IV solution attached? Or, just in case your patient crashes on you and may need the fluid or medications?

AHA 2005 taught the shock position to include lying the person on his/her back, raising the legs 10-12" and covering to keep him/her warm until additional help arrived. You weren't diagnosing it per se but if you knew someone had been in an accident and was cool, clammy and possibly altered, this was the best position to put them in. Then you call 911. So, not far fetched at all. However, AHA 2010 has changed that and raising the legs is no longer indicated. Toni

1, yes 2. I start IVs on all trauma patients...and, depending on the situation, I try to start the two large bore IVs as you will be taught in your next round of education. 3. I'm curious to see your thought process on why you think you wouldn't...especially for the pregnant patient.

Welcome, Matt. Don't be afraid to jump right in. That's the best way to learn!

I'm glad I could stimulate some really good conversation today.

Interesting thought process and hence the reason this forum rocks! The pt was the driver who had been texting when he lost control of his vehicle; minor damage.

No interference. This was wheezing. I will usually ask for clarification when I get a "did you consider" or "why didn't you". Sometimes I get it...sometimes I don't.

No ma'am. Nothing more than I gave you above. For the record...I provided no treatment other than comfort. But, my QA/QI came back with the suggestion that I could have given a neb treatment for the wheezing. I was just curious to see if anyone else would have taken that route.

Dude - you are too funny! Can't get your names or sexes right these days? Can you????

As some of you know, I like to bring these kinds of scenarios to you just to see how you might have handled a particular call. So... You are called out to a roll over. To keep it simple, your patient is fine and walking and even refuses transport/treatment. You clear c-spine in the field per protocol. There is NOTHING in his presentation that indicates he needs treatment/transport. However, you are trained to offer that ride twice and the second time he says, okay. Let's go. Your assessment shows a man who's BP is elevated (both normal HTN and the fact he just had a little excitement with his roll over) and he is tachy. As you make the 15 min trip to the closest appropriate facility, you see that both are returning (as they should) to normal. (Yes, you did do an EKG and it showed sinus tach in 12 leads.) Since you are a fantastic medic (giggle), you do a complete head to toe and listen to lung sounds. Odd...you hear wheezing. His SPO2 is 96-98% on room air, his color is fine and when you ask him about his breathing, he tells you he's breathing fine in full, complete sentences. Nothing indicates any issues. (Oh, further hx tells you that his has asthma.) So, here is the question. Do you give him a breathing treatment just because you can hear the wheezes?

I wonder if he was really feeling how strong/bounding the pulse was and when it came out of his mouth, he said rate? Did you happen to ask him to clarify for you his statement? Or, did you just accept what he said for gospel? (Yes, I know it's the latter based on your statement, "I just nodded.") You should get in to the habit of asking someone to clarify if something has been said or done that you don't understand. You will be a better student in the long run. (And this includes if you are a student/partner/commander/subordinate.) You can do it with tact so that it doesn't make you sound like you are challenging them. As a matter of fact, I would respect my student more if he/she did ask questions because, you see, we all are occasionally wrong and it keeps us all honest. Then, if it still doesn't make sense, do as you are doing now and do further research. Toni

I'm unable to view the link, so I'll let my imagination take over. ha ha However, to answer your questions. The first "first aid" thing we should teach them is the "911" number when they are old enough to learn their phone number. Then, each child is different so you will have to determine per child what they can and can not learn. The youngest I've taught thus far is around the age of 7. It was a first aid awareness type of class for the Brownies. Very short attention spans so you have to make it fun. We used dolls as our patients and I taught them how to use "stuff in the kitchen" to help stop the bleeding. We had fun. (Side note, I've also taught CPR/AED to the blind. Never discount a person's ability because of a disability.) But, teaching them how and when to call 911 for help is probably the best thing you can do. Get someone on the other end of the line who can help provide guidance. FYI, dispatchers around my area tell me frequently, they'd rather have a child call 911 for an emergency over an adult. The child, they can calm.

For the record, only the didactic portion of the class is online. One will still have clinicals and EMS ride outs to accomplish in person.

Thanks for your two cents. It was definitely not a decision entered in to lightly.

It's a school thing...

Grady, welcome to the family! I've seen you in the scenario chats...can't wait to see you get involved in our scenarios here! Toni

Had my smallest/youngest patient ever not too long ago...and it was the first time we were unable to restrain appropriately. After much discussion between my partner, the RN riding with us and me...we determined that the best course of action and need for the 30 minute old baby would be in the arms of the RN who was maintaining stimulation/warmth/blow by O2. So, mom is on the stretcher and I am in charge of her care. RN is in the captain's chair, restrained, with the new life in her arms while she was in charge of her care. OH, and our driver took an off road so that she could drive a little more slowly and carefully. The smartest move? Probably not. Only option? In our opinion. But, Waylon - here's another need for a restraint for an infant less than 20 lbs without his/her own car seat and one that needs continuous care. For the others, what would you have done in this situation? Toni

Gave you the point for the story. LOVE IT! I'm finding that one of the reasons I really love my rural service is the country folk. Most of my patients (and their family members) ask for a hug at some point and I am always obliged to give one. For those that don't know, my initials are "TLC" and I tell them there is always a little TLC provided in my patient care!