DartmouthDave

Hello, So, this guy went to the OR and everything was excised (penius,rectum, and surrounding tissues). A VAC dressing was inserted as well as a suprapubic cath. Plus, a colostomy as well. He had a high APACE II score and did poorly. He was tx with lots of IV fluids, abx, Levophed, Dopamine for a low SvO2, and APC. He had a slow, painful and problematic recovery. Developed ARDS. Was placed on ARDSNET. The works.... A pile-o-problems. Took months to get out of the ICU to the Sx Ward. I wonder what happened after that. I like this case for a few reasons. One, it was a BLS crew that responded and they actually 'exposed' and looked and knew things were going bad. Because they did a good physical assessment. Second, it shows how EMS can compliment ED care if done right. On arrival, the 1st 1000cc was in and the ball was rolling in the correct direction. Cheers...

Hello, Not in this case. In an urban/suburban area doing abx on scene will slow things down. Get the abx in once in the ED. Not that EMS can't do it rather it is an issue of time. In an urban setting the crew will have enough to do (assessment, history, lines, packaging the patient and transport). Really, the initial stages of any good evidence based Sepsis protocol. Now, in an isolated setting with long transport time abx based on the suspected source of sepsis is a good idea. Early abx equates to better outcomes. Here is a nice reference from London Health Sciences Critical Care Site: CCTC Cheers...

Hello, This fellow abd is large and soft. He has no c/o N+V. However, he has felt too sick to eat or drink. Even his beer. The BP is the same in both arms. No back or chest pain. The pain is localized down South. Here is a few questions to ponder: Hear Rate: 100-120 irregular The EKG shows A.Fib with a slight widen QRS. There is an odd sloping of the Q-wave (Delta). Alas, I have not had time to scan the 12-lead. Patient states that he has had a history of rapid heart beats. He thinks that is why he is on the Dig. What could it be? Ideas to manage the A.Fib if it gets worse? Tyl: Are we concerned with an APAP OD? Sepsis: Sepsis is a solid DX. What treatment should we start? What is the source? There is a particular condition (rare) that obese male patients are at an increased risk for down there? GU: He can not remember voiding for a long time. Impact on treating the sepsis? Cheers... Back to work...

Hello, Here is some answers to the various questions. A solid list of Dx so far. Smoking: He started 10 years ago after getting a divorced. Sputum: He has a non-productive cough. However, he has been having chills, myalgia, and fatigue. Tyl & Tly#3: He has been taking more than usual. Not so much at the start but more as the pain has escalated. He has been taking around 12 Tyl #3 in the past 12 hours. Around the same number of Advil (200mg) and Plain Tyl (325mg). Usually, He takes his medications as prescribe. HTN: He says his BP is normally very high even with the medications. Last check was around 155/95 at the Drug Store. His GP was going to increase his medications. Hernia: No hernias are noted in the abd Alternative Medicines: No odd herbal stuff. Pt says he smokes weed to relax. Once or twice a week. ETOH: A regular drinker (daily). Unable to drink for around 24 hours now. "I'm too sick to drink!!!" More of the story: A IV is started and a Ventolin neb is given. The patient is assisted to the cot. He is very weak and trembling weakly when standing. Your partner (lucky) is delegated to assess the scrotum. A vile odour is noted. The scrotum (sorry no picture Dust) appears ashen in general. Also, when lift gently (due to pain) the perineal area is black with purlent drainage. The surrounding tissues is indurated with a red and waxy appearance. A second set of VS are taken (HR 110-120 Ireg BP 100/28 Temp 39.5 BGL 22 SpO2 92 with treatment thus far). A 12-lead is done. I will add that later. Time to go to sleep now. Night shift is fast approaching. =( Also, feel free to play with the scenario. It is based on a case that came through the ICU. The main goal is brain gym. Cheers

Hello, LOL. No, there isn't a need for psychotherapy here. There just have been a few odd cases as of late around here that seem to focus on problems down South. Dust, I was typing quickly on a coffee break and neglected to include it. The BP is 110/30. The temp was taken in the patients ear. There is no history of assault or anything that the patient can recall that might be casing this pain. The patient describes quality of the pain as an aching sensation inside his scrotum and scores it as 10/10. The pain started 24 hours ago and has been getting worse. Nothing seems to make it better or worse. Cheers

Hello, You are dispatched to a suburban residence for a complaint of a painful scrotum and weakness. On arrival, you find an obese (110 kg) 52 year-old male sitting in a large chair. He looks pale with slightly laboured respiratory rate. He is shifting uncomfortably in his chair. The pain started a day ago and has been getting worse. It feels like a burning sensation. He hasn't been able to sleep or eat or drink due to the pain that her rates a 10/10. The pain dose not radiate and is localized to his scrotum. He past medical history includes HTN, DM, Asthma, GERD, High Cholesterol, Smoker (1 pack a day for 10 years), ETOH (3-6 a day), Depression, rapid heart beats and Sleep Apnea. His current medications are ASA 80mg OD, Ramipril 10mg OD, HCTZ 25mg OD, Metformin 500mg TID, Losec 20mg OD, Zantac 150mg PRN, Tly #3 PRN, Tyl PRN, Advil PRN, Crestor OD, Ventolin PRN, Digoxin OD and Tums PRN. You initial assessment shows: GCS 15 PEARL @ 4mm Strong x4 Lungs: wheezing all lobes Rate: 32 SpO2 90% HR 100-120 iregular Skin: hot and sweaty Temp 39 Abd soft and non-tender No jaundice No N+V Voding no problem but 10/10 pain that won't go away Cheers...

Hello, It will be interesting to see how this all plays out. There needs to be limits placed on 'hour of work'. It is common sense. Tired crew place themselves and patients at risk. Really, 6 x 24 hour rotation!! I assume this is a salary position as well? I hope things can be sorted out for the staff as well as the folks in Nortern Alberta. Back in the day, we used the APL ground crew in Edmonton from time to time. Nice fellows. Best of luck. Cheers

Hello, She was given Mg. It worked quite nicely on fixing the runs of polymorphic VT. Once in the hospital she was admitted to the ICU. The Bi-PAP was changed to PAV (Proportional Assisted Ventilation). This is overly simple description, but one set the 'assistance' the patient gets. So, 50% reduced 50% of the work of breathing and so on. This was a new bit of equipment in the RT department. I have been meaning to hit Up To Date and a few other references to read up on this. Alas, I have been slacking in this area. Cheers

Hello, We are talking about two different things here. Primary Health Care, according to Health Canada is: "Primary care is the element within primary health care that focusses on health care services, including health promotion, illness and injury prevention, and the diagnosis and treatment of illness and injury." Sure, a PCP and an ACP can be a part of health promotion/injury prevention activities. Or, drop by check out how a patient is coping at home. Do a risk assessment. Fine. But, they can not diagnosis and manage a patient over the long term the same way a NP or a PA can. I am not talking about an emergency here. I am talking about dealing with Mr. Smith HTN and DM. Or, Mr. Jones depression and ETOH issues. Things like that. Over an extend period of time. You think that a PCP/ACP/CCP can do this, fine. I do not. Lets agree to disagree. Besides, on your next pneumonia call at a nursing you can assess the patient, have the patient consent to you assuming care, review the patient's old charts, review the labs, talk with the family, talk with the Family Dr and then adjust the patient's medications. Prescribe some new medications; antibiotics for example. Then, add her to your practice so that you can come back later to reassess the patient because as a primary health care provider why bring her to the ED. This is not a short-term relationship. Book a CXR. Review a CXR. While you are at it leave a number to deal with family calls, patient's calls, and nursing home calls. Dr's calls. Plus, respond to 911 calls. I will now make my egress from this issue.

Hello, When I say Primary Health Care Provider I am talking about a person that can Dx, prescribe medications, refer, and follow up on their patient's primary health care needs (not emergencies) within their level of skill and knowledge. In addition, provide this level of care to all age groups. Show me a Paramedic program that covers this material? Maybe we are thinking about two different things here? Cheers

Hello, Primary health care is a specialization. Primary Health Care isn't a side project. Just like flight crews (good ones) are specialized in transport medicine. That is why I selected the ITT. They are at the top of their game because of a combination of specialization, education, training and clinical exposure. That is what I mean by 'top of their game'. The same for ORNG, the Stollery, and many more. Are they the best people for Primary Health Care. No. Because, they don't do primary health care on a regular basis. This is not a nursing bias. It is the inherent complex nature of medical care. Heck, why dose an EP need to consult a Radiologist? They learned how to read a CT in medical school. Oncologist? Nope......The GP can manage this cancer patient all on their own. Maybe tomorrow I would run the ventilators at work. Heck, who needs an RT. I understand pressure and volume cycled ventilation. Who needs them!! Even better, I can defend any protest as 'turf' war and a 'RT' bias. While I am at it, I think I will do a few CT-Angios as well. It only took the tech three years of school. Again, all protest is 'turf' war and 'bias'. How about Physical Therapy??? OT??? Speech Language??? They are all in the medical field? No, of course not. That would be foolish. We may be closer on this issue than you think. Paramedic can be a part of the primary health care team but not as independent practitioners. Yes, they can be helpful. Now, here is a fine point. Can Paramedic practice independently within their specialization (emergency care).....yes of course. If you what to do a PA or a NP job? One needs the education (2-3 years) and residency. Then sure, go for it. Cheers.... PS....yes 'muddle' was a bad selection of words...

Hello, Tniups, I agree in principal with your desire for community based paramedics programs within some of BC smaller communities. However, the model that you propose (CCP/ACP in Community Health Stations) isn't pratical for two reasons. First, the focus of training is the provision of emeregncy care not community health and primary health care. When I was in the Yukon most communities have health centers that were staffed by RN and NP with a focus on community health. They knew the primary health care side of the house very well. They basic emergency care as well. Enough to manage until a transfer was arranged. Enough that they could maintain their skills within a small quite community. So, in turn, it would be unrealistic to expect an ACP or a CCP to be at the top of their games with emergency care while simultaneously being at the top of their game with primary care. The provision of health care has specialist for a proven and valid reason. If specialization wasn't needed...well then...lets disband the ITT. Heck, we will just 'show' the ACP and CCP from the adult side of the house how to do it. Or, as a matter of fact, why train CCP. After all, they ground ACPs can just do it all, now. This point may be over the top. However, what I want to say is 'Primary Health Care' is complex to master and isn't something that can be a side project any more than being ACP(f) or CCP or in the ITT can be. Second, suppy and demand. BC has many problems with EMS. One thing that is good is sending ALS to ALS calls. This keeps a small cadre of well trained staff (..could be a little bigger...an other issue...). This keeps the provides well tuned. As opposed to an ACP that may tube 3-4 times a year, for example. To have an ACP or CCP sitting in a small town waiting for something to happen or muddle throught primary health care is a misallocation of resources. Now, at the PCP level there are numerous community paramedic programs that work well (Long Island, NS...for one). Yes, this is a good idea. IMHO... Cheers

Hello, Hard, because, 3,4 & 5 are all a family I assume. I just would want the infant with family. #1 & #3 (one ambulance) #4 & #5 (one ambulance) #2 (one ambulance) I assume that #2 will be last due getting him out of the car he is in. Basically, a copy plans above. As for crew set up. Not a huge issue with a 6 minute ETA to a two different trauma ctrs. Cheers

Hello, Rock Shoes. Yes, hyperuricemia is the reason why this lady was on the Allopurinol. Chbare added to this with Tumor Lysis Syndrome (TLS). Which was this lady actual Dx once she arrived in the hospital. Her multi-vitamins were a standard over the counter brand. She has a wasted appearance and has been losing weight. Her EKG shows Sinus Tachycardia with numerous multifocal PVC and runs of ploymorphic VT. The hyperkalemia was managed but there is an other issue lurking here. Current Situation The patient is on the cot connected to the monitor. Access is obtained via PICC or EJ (crew preference). Treatment as outlined about plus she is given Ativan 1mg SL and she has settled some. Current VS are: GCS 14/15 Drowsy, eyes open to voice BP 170/98 HR 100 (EKG as noted above) SpO2 88-89 (+10/+5) Rate 30's loboured The wheels start rolling to the ED. Any other considerations? Here is a general Wikipedia article on TLS. I have an Up To Date article I will try to add later. TLS Cheers...

Hello, I think a PICC is a safe option here. Sure, an EJ would work. But, why risk it if you have a perfectly function PICC line? As for Perm-Caths and Quinton more cation would be required and an EJ would be a better go. IMHO. Cheers

Hello, The PICC is a triple lumen line so lots of room. The general consensus is: - Start Bi-Pap - Go for the PICC - Give NTG .4mg SL - CalCl, NaHCO3, Insul, D50W, Ventolin for the peaked 't' waves - Consider Lasix IV Response to treatment: Once the Bi-Pap mask is applied the patient settles some. Her SpO2 creeps up to 86% and her rate is in the 30's NTG drops the BP some (BP 170/80). The T-waves are coming down slowly. She is still quite tachy with numerous multifocal PVC's. With what appears to be occasional runs of polymorphic VT (6-8 complexes). During these runs her LOC decreases. The patient is quite anxious as well. Her husband wants to give her an Ativan. He finds it makes her breathing better. From time to time she try to pull the mask off. Pardon any typos....trying to knock this post off while at work. Here is a hint as to the patho of the renal failure. Think about the lysis of tumors from the chemo. =) Cheers....

Hello, Here is some more: Airway/Breathing: The patient is dose not want intubation at all. I forgot to add the SPO2. The monitor shows 82% on room air. So, CPAP or BI-PAP is a solid option. Circulation: As noted above. Gross edema. An IV looks impossible. So, the PICC would seem to be the only option here. The EKG shows Sinus Tachycardia with peaked T waves. Also, there is a fair degree of irritability as evident by numerous multifocal PVC's (one every 2-3 seconds or so). Additional History & Assessment Information: A BGL is done. He blood sugar is 12.5 The husband say the cancer is 'bad' (terminal) and the chemo was done to 'Give her more time.' She is a DNR (No CPR or Shock) but wants active treatment including ICU admission. Her renal function was fine. She was voiding fine until recently. The Allopurinol was started a few months ago to manage a complication of her cytotoxic therapy. She has been compliant with taking her medications. She hasn't been eating well at all. She has been losing weight. Sometimes, she takes a multivitamin. It was suggested by a Dietitian. But, she dose not take it often because it upsets her stomach. Treatments Considered: NTG? Dose? IV? SL? Lasix? Dose? CPAP/BI-PAP Settings? Any considerations for the EKG? Causes? Treatment? Ventolin? Ativan? So, why may be the cause of the renal issues? Use the PICC? I hope this helps. Some brain gym. I based this case on an interesting patient that came through the ICU quite a few months back. Off for yet an other night shift. =( Cheers

Hello, You are dispatched to a rurual home 30km from town for SOB. Upon arrival you find a 55 year-old frail looking female in obvious distress. She is hunched forward, tachypenic, and using assessory muscles. Her colour is pale. She is very anxious. She is surrounded by a large and loving family that is on the verge of panic. Her husband states that he wanted to call an ambulance yesterday but his wife wouldn't let him. He says that she has cancer (lymphomas)and that she has been getting cytotoxic therapy and has been going down hill over the past three days. She has not voided for the past 24 hours. On exam; GCS 15 BP 190/110 HR 120 irregular/bounding Temp 39 Generalized pitting edema. Lungs have course crackles in all lobes. Elevated JVD. A PICC line is note in her right arm. An old surgical scar is noted in her lumbar region (Laminectomy). Her past medical history is obtained from the husband. Her history includes lower back pain and a Laminectomy 5 years ago. Lymphomas with some renal issues. The husband can not remember more about her renal issues. Her current midications are Colace BID, Hydromorphone 2mg PRN, Allopurinol 400mp BID, Ativan 1mg SL PRN, Venalfaxine 150mg OD and Immovaine 15mg QHS. What would you do and why? Cheers....

Hello, I should change my profile. I worked in the Yukon up until the summer of 2008. Right now, I live in Northern BC. Just haven't got around to it. I think it is reasonable for an ED have SOP to keep things moving. Without waiting for the EP. It is simple supply and demand. The EP can only be in one place at one time. IMHO. Cheers

Hello, Personally, I am indifferent as to who dose intra-facility critical care transport in BC. What I want is actual ground critical care transport resources available in a timely fashion. In reality, what happens now is the sending facility sends staff with the BLS crew. In fact, this week we have had three admission to the ICU all brought in via BCAS with accompaning hospital staff. This is wasteful. You tie up a ambulance crew AND hospital staff. As for flight. I find the BCAS flight temas older, relaxed and expereinced. Response times tend to be slow (from my point of view) due to limited numbers of crews and planes. The same for ITT. But, I would like to add that nurses are capable of filling this role. There are excellent systems that use nurses. But, in BC, the logical solution is to build on the system that is already functioning. Not intend for a 'flame war'. Just waving the flag that is all. =) The NP vs Community Paramedic. There is room for both. But, I think on the Paramdic side of the house doing two jobs (EMS & Primary Health Care) wouldn't work well unless the station is very slow. The example I like to cite is Long and Brie Island in Nova Scotia. Even there, their scope is limited when compared to NP. So, to sum up, Community Paramedics can work in a few selected areas. Also, considering the educational background for a NP is a Master Degree it would be hard to match this with suplamental training in addition to one PCP or ACP training. As for Paramedics doing Traige. Yes. Can they do it better and faster than a nurse? I say that that is an individual issues that transcends one profession. I have done triage. Sometimes, you need to wear two hats; being the charge nurse and triage. Trying to sort out bed issues. Trying to move a patient to ICU. Dealing lots of other crap....to put it bluntly. If all I had to do was triage was I would be moving a light speed! As for 'Dr orders'...... I think that beyond the typical standing orders (...CP, SOB, ect...) that one will find in any good ED (..that in many ways mirror EMS protocols..) Paramedics won't find a greater degree of freedom becasue at the end of the day the DR is the 'most responsible' provider. Cheers

Hello, What specialized paramedic positions are we talking about in BC? The only thing that I can think of is air ambulance off hand. But, I am not sure. For the BCNU that seems like a small target when compared to pushing for NP and things like that. As for Paramedics working in different areas in the hospital. This is a good think. For example, when I work in Halifax a few years back Paramedics staffed the Triage Desk in the ED. Or, having a patient holding area staffed by Paramedics in the ED. Thereby freeing up crews waiting to transfer care of their patients. Being exposed to treatment and management of patients within the hospital only could improve one's clinical skills and knowledge base. IMHO. There is a shortage in nursing. For the most part the shortage is in special care area (NICU,ICU,CCU,ED) due to the time required to gain the skills and knowledge necessary to be proficient in these settings. Also, lets not forget about the burn out rate. Plus, in the entry level ward positions were one spends there dealing with high acuity patients and bad staffing ratios are always short. Heck, just looking at any hospital nursing positions open and you will see plenty unfilled positions in theses areas. Cheers

Hello, The Aortic Aneurysm could be the cause of the chest pain as well. A Thoracic Aortic Aneurysm (TA)can present with SOB, coughing and chest pain. As opposed to the tearing type lower back pain of a AAA. Basically, a TA can pain fairly convincing AMI picture. In fact, Thoracic Aneurysm (TA) is a DDX that one must rule out in the hospital setting before TNK is given or the more aggressive treatments for a AMI. Sometimes, in theory, their can be a difference in BP from arm to arm in a TA. However, I have never seen this myself. Cheers....

Hello BoCat9, No need to be sorry about anything. Posting is hard sometimes. In fact, I have been mostly a lurker since 2005! =) There are a great deal of possible causes of PVC's as you know. In the case of a AMI PVS's typically are left alone. Relaxing the patient (being kind and maybe an Ativan) can help reduce PVC. As well as oxygen in and pain control. Though not a concern in the EMS setting lytes play a key role in reducing PVC. AMI patient typically have their K and Mag kept the high end of normal as well. Plus, if there are no signs of failure IV Metoprolol helps sooth things as well. Cheers....

Hello, Levi and Chbare are right on target. Once in the ED the seizures were attributed to Demerol toxicity. The patient has been taking excessive doses of oral Demerol. Plus, prior to visiting her Aunt she had three ED visits and was given IV Demerol as well. No CT was done. A urine screen was only positive for Opiates. Her urine was +3 for blood, lukes and proteins. Her Serum HCG was negative. As well as Tyl and ASA. She was give NS and Dilaudid IV (2-4mg IV) for pain control. She stated that she felt nauseated and wanted some Gravol IV as well. She was given 50mg IV and stared on Septra DS for a UTI. She also c/o a history of urine retention as well. In fact, she stated that she has needed In & Out caths from time to time. This could be from the narcotic or Gravol use I though. Also, I question her how much Gravol and Demerol she took per day. She was vague on these points. This girl was in pain, for sure. But, there is some mental health issues as well. Cheers....

Hello, So, what is a possible cause of this patient's seizures? Would you treat the pain? The patient's LOC improves quickly. She is c/o pain. She wants to take Demerol 200mg PO before you leave to the hospital. She says the Drs and Nurses never believe her pain is that bad and that her Dx isn't real. What do you think? Cheers