Bieber

Yes, I'm en route now. Let's go to the nearest appropriate facility (cath lab minimum, preferably with the ability to do a CABG as well). How is the patient's pain now? Are we having any change at all in the severity or quality of the pain? Let's give a nitrotab every five minutes, and go ahead with 1 mcg/kg of fentanyl if the patient's still having pain after x3 nitro as long as we maintain a pressure >100 systolic. P_Instructor, if the patient is having a pneumothorax small enough to remain undetected, do you think it would still be enough to cause the patient this much distress? I haven't yet encountered a pneumothorax of any kind, but I would think it'd have to be fairly large to cause so much discomfort.

Glucagon's a smooth muscle relaxant, though I think I'd probably try a couple other things before I went to it, considering it'll have beta agonist effects as well and in a patient complaining of chest pain. I agree with Dwayne on the ASA, and why don't we pop a nitro and see if that does anything? You said her lungs were clear, right? I'm gonna go down the cardiac route, get my line if I don't have it already, NS TKO, and do serial 12-leads at this point. I'm concerned right now that this could either be an atypical MI or possibly a PE. Let's reassess!

Clear lung sounds and pretty decent O2 sats? I'm thinking there's more to this picture than meets the eye, especially considering she's an older woman and a diabetic. Let's get her moved into the truck ASAP and get a 12-lead EKG. Tell me about this chest tightness, where is it exactly? Does it feel deep or close to the surface? Is it going anywhere? Is it constant/intermittent? Has it been getting better/worse since it started or staying the same? Anything she's done to try and make it better or worse? Any other history, meds, or allergies? Has this ever happened to her before? HEENT: Any perioral cyanosis or nasal flaring? Neck: JVD, retractions, tracheal deviation, subcutaneous emphysema? Chest: Depth of respiration? Equality of chest rise? CABG scar or palpable implanted defibrillator/pacemaker? Abdomen: Soft/rigid, any bruising, distention, pain/tenderness? Pelvis: I presume it's stable since she is able to bear weight. Posterior: Anything significant? Extremities: Neurovascular function? Cap refill? Numbness/tingling? As for vitals, I'd also like: Pain rating. BGL. Treatment wise, let's go ahead and put her on 15 lpm via NC. I'm hesitant to give her high flow O2 if this is a potential cardiac event, especially if she has clear lungs and good sats, but at the same time I want to give her some relief as well. If we need to adjust that later we will. Let's also get an IV of NS TKO.

FireEMT, great scenario! Thanks for sharing it! Dwayne, 90 seems to be the magic number people are liking nowadays--mostly in trauma, but from what I've heard that seems to extend to all patients as well. Ultimately, what I want to obtain is good perfusion to the patient's brain and vital organs, though since he's actually lost fluids, perhaps I should aim that number a little higher. Hmm...

Dwayne, Visual inspection of the mouth reveals several large avulsions to the interior tissue, however you note that much of the blood is also coming from the lacerations surrounding the outside of the mouth. When you try to pack the inside of the mouth, you nearly get your finger bitten off by the patient! The patient doesn't struggle, but he continues to curse at you for being a "jackass". His vital signs remain unchanged throughout the remainder of the transport and you're somewhat able to staunch the flow of blood with bandaging. The patient was also able to maintain his own airway with frequent suctioning of his oropharynx and had clear lung sounds and good oxygen sats the whole way in. When you arrive at the hospital, the trauma team is waiting for you where they immediately RSI the patient and ultrasound his belly before he is taken to have a CT of his head done. Your truck is then put unavailable while you and your partner go to get your blood drawn and fill out three hours of paperwork relating to the blood exposure. Now you always carry a mask with a face shield and an N-95 respirator in your pocket when you're working. Thankfully, you find out that the patient's fast HIV came back negative and don't have to suffer through a month of combivir. You later find out that the patient is discharged within two days with a diagnosis of a fractured right patella along with two small brain bleeds: a subdural and a subarachnoid. No internal abdominal bleeding was found on the ultrasound. Thanks for playing, guys! This was the call that I got the blood exposure on. =) Hope you enjoyed it and learned something from it, I know I did!

Let's go ahead and titrate our NS to try and get and maintain a pressure of around 90 systolic. Any changes in LOC? We'll call the hospital back for insurance information later!

Well, I think that's all I got. It sounds like organophosphate poisoning to me, though hopefully we can get some samples of that powder to the hospital for analysis. At this point, I'm gonna go ahead and open up that line since his pressure's staying pretty low and bolus in 250 cc of NS and reassess his pressure and vitals and we'll just take him in. If the patient's breathing spontaneously and adequately now we can stop assisting ventilations.

12 lead shows a sinus tachycardia, no ST elevation/depression or T-wave inversion or any other appreciable abnormalities. The temperature outside is in the high 80's, low 90's. Cap refill is about 3 sec. Son says his father is allergic to penicillin, has an unknown cardiac history, doesn't know any other medications besides something that starts with "warf". He doesn't know anything else aside from the fact that the patient's been consuming copious amounts of ETOH tonight.

Most recent example I can think of was having to tell a blood spitter (in no kind terms) to STOP spitting blood everywhere so we could work on him. Another one that comes to mind was a patient with atrial flutter at a rate of 280 who wanted to turn every question into a life story. Eventually, we just had to tell her to just give us yes or no answers so we could try and get a full history on her; even that wasn't working so great, though. Mind you, we apologized to her and explained that we weren't trying to be mean, but we needed to get some information on her.

Yeah, I'm afraid I occasionally suffer from a minor case of head-in-ass syndrome. There's no known cure, but with treatment I should be able to live to a ripe old age. Let's just keep going with the 2 mg atropine until we either dry his secretions up completely or until signs of atropinization occur. It would have been nice to check his wallet and phone, but those are probably in the bag with the rest of his clothes. Oh! Why don't we send somebody to run inside real quick and look for any phone numbers for friends/family/work (especially work)? See if we can't get a hold of somebody and find out what he was exposed to. Let's get a sugar on him as well, and reassess his LOC. After that, and unless we can get any more information out of his neighbors or contact his work, I'd say let's get him rolling. I'm still thinking this is some sort of organophosphate poisoning, but there's a lot of unanswered questions. He was in his pajamas, so he must not have been at work, but we didn't find anything in or around his house? Is he a smoker? Any other medical history, meds or allergies we were able to get out of the neighbors or anything we found on scene? EDIT: Also, any recent history of illness? Travel outside of the country, even?

FireEMT, you successfully suction out the patient's airway again, but I bet by now you know what's gonna keep happening, don't you? Bystander states he is the patient's son and that the patient was consuming ETOH tonight (the smell of which is evident on his breath) when he drove down the street on his moped at sixty miles per hour and "wiped out". Oh, and he also mentions that the patient has a "heart history" and takes something that starts with "warf". You note no battle signs, however the patient's face is still completely covered in blood. If you didn't know better, you'd almost say someone had torn off the epidermis on his face. You also successfully put on the NRB, and the patient is pretty much able to maintain his own airway, though he continuously turns his head to the side and spits or demands you suction him out. Once you get in the back of the truck, one of the fire guys offers to drive you in so you and Dwayne can dual medic it in the back. You are between fifteen and twenty minutes away from the nearest trauma center (closer to fifteen, thanks to the low traffic at night). HEMS is available. Dwayne, GOOD PLAN! You get masked up and get your truck set up. The patient just lies there. He moves his head to turn it on the side to spit, and moves his hands around emphatically, even when you tell him to stop, but he's not combative--just uncooperative. When you try to tell him what happened and that you're there to help and take him into the hospital, he responds with a "F*** you!" and also rants about you and FireEMT being assholes, but otherwise refuses to answer any questions. Once you get him in the back of the truck, you guys get him naked and note the following: HEENT: Eyes are swollen shut, and you are unable to assess his pupils. The blood is making his eyelids too slippery to raise. Everything else is as before, and if not for the fact that you can see the rest of his body you would have no clue what color his skin was. Attempts at mopping up the blood seem futile, and his facial wounds continue to bleed slow but steady. Neck: Same as before. Chest: No soft tissue injuries or deformity of the chest wall noted. No subcutaneous emphysema. Abdomen: Upper left and right quadrants are soft, with no bruising, distention or guarding. Upper and lower right quadrants are rigid, with bruising noted and guarding present. Pelvis: Patient is incontinent of urine, no priapism or soft tissue injuries present. Pelvis is still stable. Posterior: Same as before. Extremities: Patient continues to demonstrate normal motor function with no gross deficits, vascular function is intact in all extremities. Significant bruising is noted to the right knee, and patient has multiple small abrasions on both lower extremities. Upper extremities are the same. Also note patient's skin feels very cool to the touch and appears pale. You get your lines, and you're easily able to restrain the patient with the soft restraints. EKG shows a sinus tachycardia with no ectopy. With constant suctioning, you're able to maintain a patent airway. Vital signs now: HR: 100 RR: 24 BP: 108/76

Oh jeez, I suddenly realized my mistake. Sorry, guys, I haven't reviewed this stuff in a while--what was I thinking? Let me go ahead and get my head out of my ass for a second and then we'll go ahead and give this guy a man size dose of atropine. Let's go with 2 mg and keep suctioning those secretions, we can give another albuterol as well.

Oh jeez, you really want to make me work, don't you? All right, well, I don't want to move him into the back of the truck just yet. Let's get some masks and gowns on everyone and consider this a possibly contaminated patient. What do we see around the house? What kind of area are we in, anyway? Farming land, maybe? Send somebody out to look around the outside of the house (along with the garage and shed if there is one) for any pesticides or the like. Let's strip him down and bag his clothes, and rinse his skin off with copious amounts of sterile water! After we rinse him off and dry him off, let's also put him on the monitor, get a quick 12-lead to make sure there's nothing going on in there, and if there isn't, let's go ahead and get a line on scene and pop 0.5 mg of atropine. While we're doing that, can we have somebody inspect the inside of his mouth, suction out any secretions, and maybe even start assisting ventilations to try and slow his respirations down with a BVM at 15 lpm and administer a dose of albuterol as well. Now let's reassess our interventions! And maybe think about getting headed toward the truck once we have the patient thoroughly deconned. Right now I'm strongly suspicious for organophosphate poisoning or some type of cholinergic poisoning. Oh hey! That reminds me. Mr. Neighbor, does the owner of this house keep any pesticides or the like around?

As you approach the patient, he spits blood in both you and your partner's faces and yells "Get that f'**in' light out of my face!" He speaks appropriately, though he has blood in his mouth, but refuses to respond to your questions. Though he is not cooperative, he is not combative. You and your partner (who had not been wearing face masks) are covered from the waist up in blood spray! Vitals as noted at this time are: HR: 88 RR: 22 BP: 110/78 Visible injuries: HEENT: Massive swelling to the zygomatic processes bilaterally with crepitus felt beneath, lacerations to his mouth and scalp which are bleeding steadily, swelling around his eyes prevents the patient from opening them. No deformity to any other bones of the skull noted. Copious amounts of blood in the mouth, which he continues to spit out without regard for his aim. Neck: No JVD, retractions, tracheal deviation, subcutaneous emphysema, deformity to the cervical spine (assessing for pain meets the response "F*** you!") Chest: Patient is wearing an intact T-shirt at this time. No abnormal chest wall movement is noted through the shirt, however. Abdomen: See above. Pelvis: Patient is wearing jeans which are intact. Pelvis is stable. Posterior: Upon log rolling the patient, you lift up his shirt and note no soft tissue injury or deformity to the back or the chest wall or spine. Extremities: Intact with no deformity noted. You do see a couple of abrasions to the patient's forearms, and his hands are covered in blood. Vascular and motor function are in tact, patient refuses to answer you when questioned about his sensation. You suction the patient's mouth out and manage to clear it, however you note that it is quickly filling with blood once again. Fire crews arrive and begin to assist you with immobilizing the patient. EDIT: Also! A bystander is on scene if you'd like to ask him any questions. And as another note, the patient's age is currently indeterminate due to the blood covering his entire face; however he is obviously an adult male.

You are working with your paramedic partner in a small town just outside the big city of the county you work in when you are dispatched to a moped accident. It is around 2300, and you respond lights and sirens to the intersection of a street with no traffic on it where you find the driver of a moped lying supine in the street. The moped is about twenty feet away with no major damage, however from the truck you can see that the patient's face is covered in blood. You are first on scene but can already see the BLS fire units' lights in the distance. Go!

Let's have somebody take C-spine and we'll role him onto his back after clearing any glass out of the way and make sure his airway's open. From there, why don't we... Assess his LOC. Assess his respirations (lung sounds, rate, depth). Assess his perfusion status (radial pulse, rate and quality; skin condition). Then let's have somebody get a set of vital signs (HR, BP, SpO2, BGL), I'll go ahead and do a quick head to toe. What do we have in terms of injuries? Also, guys, please be careful of the glass if you're gonna be kneeling down!

We don't have badges, except on our dress uniforms (and I'm not special enough to have a dress uniform yet), though we do have some small pins we were on the left breast (and by we, I mean full-timers, part-timers don't get 'em). Badges are cool from a certain perspective, but really, I'm not a cop, I don't enforce the law, I don't need anymore proof than my ID badge, ambulance, and uniform and the fact that I mysteriously appeared right after you called 911 to prove who I am. We're medical providers and I feel we should look like them, and stop skirting the line between public safety officer and ER caregiver. One or the other, because this whole deal of trying to have the best of both worlds is really just making us the red headed stepchild of both.

First of all, you are the first person to ever call me "Mr." Bieber, which is hilarious in and of itself. =P Secondly, and don't take this like I'm trying to criticize you or anything 'cause I've only been a paramedic for six months, but why aren't you a fan of using IO's unless they're absolutely necessary? I completely agree with the first thing you said about the patient being one hundred percent critical. While we may only see the beginning of DKA, once it's just getting bad enough for them to call 911 for help, the truth is patient's with these high sugars have already bought themselves a stay in the ICU, and the lab chemistries that get out of wack by hyperglycemia can have very serious, life-threatening and life-changing consequences. I also did mean you, and agree that IO's and EJ's are taken way too seriously. It's a tool, one that in the wrong hands can have serious consequences, at the same time, it's one of those things where you have to way the risks and benefits and I think that the risks are sometimes overhyped due to the simple idea of drilling a hole into someone's bone. Yes, like any invasive procedure, it can have dire and even life-threatening consequences. At the same time, I don't believe it's SO dangerous that you should feel you like you have to have a code blue to whip it out. Use it when you need it, and learn to recognize when you need it (and when I come across that patient that I need to do an IO on, I'll be sure to share it with everyone to let you know my experience!). Take care. -Bieber

On duty: wallet keys (car and ambulance) radio pocket drug guide protocol reference cards N-95 and mask with face shield (started carrying this after my blood exposure incident) trauma shears stethoscope one or two pairs of gloves pen, notepad and some forms (privacy info act, paper copy of refusal in case the tablet stops working, PCS) Off duty: wallet keys phone

Hmm, this is a good scenario, and I'm not sure I can give you a straight answer! I know at least one crew that is big on starting IO's if they need them, but most of the partners I've worked with seem somewhat hesitant to. In this case, it's a question of risk/benefit. What are the risks of NOT having a line on this patient? Are you comfortable not having one on her? What are the benefits of a line? Yeah, you can give her fluids, but depending on how long your transport time is, will you be able to give her enough to make a difference? She bought herself a stay in the ICU, that's for sure, and like Herbie said, she'll probably get a central line not to mention insulin (which doesn't need a line to be administered) to bring her sugars down. I suppose if it were me, I would probably just keep trying to get an IV (even trying the EJ) and hold off on the hospital (keep in mind, my transport times are usually around 15 minutes). But at the same time, you don't want to be afraid to bust out the IO if you need it, and if you had started one on this patient, I wouldn't knock you for it. Yeah, it carries some risks with it, but it's also not this humongous super-scary thing that it sounds like. Hope that helps.

Tell that CNA that I'm pretty stupid and I don't know what "weird" means. She's gonna have to be a lot more specific. Was it a droop she saw? If so, how pronounced? Did she assess it further? Does the patient recall having any symptoms at the time of the episode? At this point, the patient is alert and oriented and--at least around here--can make their own decisions. DPOA doesn't take effect until the patient is no longer competent to make those decisions on their own. I want to make sure that the patient understands the risks involved in not going with us (could have been a TIA, could have been any number of things I can't assess for or diagnose in the field), but ultimately, if she doesn't want to go I can't make her. Let's hang around while the DPOA shows up and see if anything changes, maybe check another set of vitals and do another stroke screen.

Could be a TIA. -Does the patient have any complaints? -What does the patient say about what happened? Who witnessed the episode? CNA or RN? Anyone else? What do they say happened? If it's the RN, I'd like to speak to her, please. =) And, most important of all: -What does the PATIENT want to do?

No exposure, no need to report. I actually had an exposure a couple of weeks ago, though. First on scene for a moped accident, driver had ETOH on board with massive facial trauma. We walk up to him, shine a light in his face to see what we have, he tells us to get that "fucking light out of my face" and spits blood in both our faces. The fast HIV came back negative on him, so we didn't have to go on any prophylactic meds, but needless to say, now I carry a mask with a face shield in my pocket at all times.

Can't say I've ever seen a hemo- or pneumothorax yet! I eagerly await the opportunity to decompress a pneumo, though. Come to think of it, I haven't ever run any stabbings either; though I recently had a knife wound to the back (slashing injury), but it didn't go much deeper than the dermis.