Aussieaid

I can't think of anything that should have been done that was not done according to the OP's report so not sure what you think he missed? You also have made an assumption that because he realized the pt was old and (probably) dying that he did not work them up adequately whereas it seems that the appropriate treatments and measures were taken. (i.e. 12 lead looking at the chest pain as well as treating as a trauma pt as far as I can tell). He may have been looking back in hindsight and understanding that the pt's co-morbidities were the cause of his death versus any lack of care on the medic's part. It is also an assumption that taking note of his age and condition caused them to decrease their level of suspicion for occult injuries and complicating factors whereas he did not say whether or not it may have instead raised their alertness to more potential complications. He was obviously taking into account the geriatric considerations or else he would not have been saying that "as far as 90 y/o patients go he was very healthy and I hope to be that healty [sic] at his age". Exactly! The question the OP was asking was what else could they have done and was it possible they missed something that resulted in his death. I didn't see anything listed in their treatments that indicated they missed something that resulted in his death or else I believe in all likelihood he would not have lasted a couple more days. It seems they provided appropriate care for all his possible conditions/co-morbidities and I don't see anything else that should have been done prehospital that wasn't. Cheers!

He most likely died from complications of old age versus anything from the accident although the stress of the accident may have compromised him further. He was 90 years old and she was transporting him for general weakness which could be from a myriad of causes at his age. Whatever the cause, it is more likely what he ultimately succumbed to rather than the accident. I don't think EMS necessarily missed anything from what you tell us was done. If they had missed something vital he would probably have died before 2 days after the event. Cheers! (Edited for a "senior moment"!!)

Some pesticides contain methylene chloride which can metabolize to CO hence the CO poisoning symptoms are the same.

Just some points to consider: Pt has a history of MI and ventolin has been known to cause MI even in pt's with no known cardiac history. Beta blockers are given in both AMIs and CHF so giving ventolin is going to have the exact opposite effect. If the pt has had no relief from his own ventolin (albuterol) and develops crushing chest pain with further ventolin with a history of angina and MI's would it not make sense that perhaps the treatment is causing the problem? Do you think that possibly his breathing difficulties could have been caused by CHF? Wheezing in the bases versus throughout all the lung fields makes me think more CHF than asthma not that you can't have it in both but looking at the whole picture I would be leaning towards cardiac. (By the way "cardiac asthma" = CHF) Perhaps the dust was coincidental or it could have triggered SOB with already developing CHF. What were his SpO2 levels? Do you have 12 lead capability? It could also have been an asthma attack and they developed an MI from the ventolin. If they were above 90% and not improving with the ventolin and it was causing chest pain perhaps it would be prudent to stop the ventolin, continue providing O2 (possible CPAP if you have it) and treat the chest pain. Or treat the chest pain and if he deteriorates instead of improving (with his respiratory status) then restart the ventolin once his heart rate has decreased and chest pain improved. I wasn't there and don't have the whole picture but just remember that some of our treatments can actually cause more damage if we are mistreating something. Pain is an indication of a problem and it can be to your detriment if you ignore it. Tachycardia in an MI can increase the ischemia and area of infarction. You were on the right track of reassessing with changes in patient condition and in questioning if your treatment was actually causing more harm. Keep on with the critical thinking! Remember "First do no harm!" (Sorry I know you have already answered a couple of the questions but I had typed this all out and thought it was posted but it didn't save. So am reposting without editing because I am too lazy!!!)

Since we have an abundance of anecdotal stories I will share a couple of calls I was actually on. The first one was an interfacility transport for a patient who had tipped his quad motorbike over onto it's side the previous evening. Being a tough farmer he walked home and went to bed. The ambulance was called in the morning when he had trouble getting out of bed but no other obvious neuro deficits. At the local hospital a c-spine xray was done which showed a high cervical fracture at which point a c-collar was placed and we were called to transport him to a trauma center. When we arrived he had no other deficits except mild weakness and mild neck pain. We fully immobilized the patient for transport on a blanket padded backboard with no problems en route. I agree with the people who pad their backboards and do it everytime without any problems with the patients sliding. This pt ended up having an unstable C2 fracture as well as lumbar and sternal fractures. This guy was very LUCKY! Number 2 was a scene call in which the vehicle did a couple of 360's and hit an embankment. Minor damage to the vehicle and only one person with an injury. This pt had no outward signs of trauma and was moving everything until a friend tried to help them out of the vehicle at which point they became a complete quadriplegic from such a severe injury to their neck that there was nothing the Drs can do to treat it. (Multiple, complex cervical fractures with a completely transected cord) Number 3 helps perpetuate the c-collar/immobilization controversy. Another scene call in which the patient almost decapitated themselves with their motorcycle helmet strap. Luckily they missed major vessels but it looked like their throat had been cut. Because of trauma to the neck at the level of the hyoid bone a c-collar was not placed and the pt was immobilized with BB and a CID only and padding over the wound (PTA). We intubated the patient for a number of reasons and kept him paralyzed post intubation so he was not at risk of moving. Afterwards the neurosurgeon told us that with this patient's particular type of unstable high cervical fracture that if a c-collar had been applied the patient would probably have ended up paralyzed. As it was he had no neuro deficits with the injury. Another super lucky guy! Still this was one of those rare injuries where a c-collar can actually hurt rather than help. On another note that X-collar looks like it would make intubation a little tricky!

One of the reasons Etomidate is controversial in peds and certain subsets of pts (i.e. sepsis) is because of it's adrenal suppression. This can be offset with corticosteroid administration but it is generally not recommended to give multiple doses of it. With our RSI protocol we are not allowed to repeat the dose of Etomidate and have to go to a different sedative if needed. Etomidate is shorter acting than Ketamine which is good in some situations. The big difference to remember between Etomidate and Ketamine is that Etomidate has NO analgesic properties and should be given in conjunction with a narcotic for painful procedures. A problem with Ketamine is emergence delirium but it can be offset with a dose of versed given concurrently. I think because of the adrenal suppression issue as well as the potent analgesic effect I have seen Ketamine used more in the PICU setting. I have personally only seen Etomidate used for RSI. PCP- the milky white substance you saw was most likely Propofol which is a very short acting hypnotic that also has no analgesic effects. The good thing about it is that it wears off very quickly which is why it is usually given as an infusion unless it is for induction. The bad thing about it is that it can make a pt very hypotensive and in a stimulus rich environment (such as transport) you may have to give higher doses to keep them adequately sedated which increases the hypotension. Just my rambling middle of the night take on the main differences. There is plenty of literature about them all for more in depth information. There are other pro's and con's for Etomidate versus Ketamine but that can be for another time. Cheers!

Divert to the nearest ER for emergency c-section. Standard of care to monitor FHR frequently on a high risk OB transport.

Ummmm....don't go in!

Thank you for your replies. They were helpful and along with advice from other colleagues I have resolved on a plan of action: Talking to my Supervisor and Medical Director. The equipment I am talking about is a fetal doppler for high risk OB transports. I think it may have been an oversight that we don't have one as it is even mentioned in our protocols to monitor the FHR. They just haven't supplied us with the equipment. I will be happy to donate mine (well, maybe donate with reimbursement!!). I do know that I will not be doing any OB transports without at least a fetal doppler. To not have any means of monitoring fetal well being in transport is a lawsuit waiting to happen. OB has the highest rate of litigation of any medical field. I am not going to put my licence at risk for an oversight (hopefully). I was advised that since my doppler is not being covered by biomed with the company I could be liable so will take the safe option and get them to get me one! Thanks again for your opinions!

So I have a question and hope someone has some ideas for me. What would be the legalities of using a piece of equipment that you supply yourself which is not supplied by your employer? Non-invasive equipment...monitoring equipment that you have training and education on. The reason I have the equipment is because it is not supplied by my employer and I am professionally uncomfortable doing certain transports without it as I feel it is lowering the level of care to not have it. I feel like my licence is at risk even though my employer doesn't supply the equipment when I know better and have it myself. And, yes I will be raising the issue with my employers and am actually considering turning down certain transports because I don't have the equipment (supplied by my employer). Any and all thoughts will be appreciated....

Not sure what you mean by this? An infiltrated IV is going to have exactly the same effect as a missed IO - fluids and medications going into the tissues instead of the vein or osseous. It will just be in a different location. And just for the record an infiltrated IV can be extremely serious depending on what drugs have been extravasated. I have seen people lose limbs from infiltrated IVs. Found an interesting ScScandinavian retrospective IOstudy.

I use the dispatch info to prepare me for whether it is a trauma or a medical call and even then it can be something completely different. We were dispatched for a "cut to the hand" once and made me wonder why they needed a helicopter. I was already looking for a bandaid and thinking along the lines of getting the local hospital to accept them. The patient had a rather large "cut" to the hand and it was still inside the lawnmower while we flew the pt with barely controllable hemorrhaging! We NEVER take our interfacility calls at face value. We were once dispatched for a pt with 14 IV drips when it turned out she had a 14g IV in!!!! It's really easy to take things at face value and most of the time we do no harm but there is that occasional call that we get "tunnel vision" on and find out later we weren't even in the same country. We are the ones who have to live with ourselves when we do do harm because we accepted what we were told at face value without doing a thorough assessment of our own. Sometimes we just need reminding to not get complacent and it is good practice to think of as many possible differential diagnoses as we can to keep us on our toes. Cheers and Happy Turkey Day!

Welcome to the City, Brian! Lucky you to be living in Nanaimo, BC. Do you have to go to the mainland for the busier station? Good luck with the new job and position. Don't ever stop learning and keep your compassion no matter what. And of course...safety first above all else!! Hope you enjoy the City and learn and share your experiences. Some good folk on here. Have a great Thanksgiving (or is it already over in Canada? I can't remember.) and Holiday Season and keep safe (and warm!!!) Cheers Aussie.

Excellent case study. Strong work going with your instincts and taking this guy to a trauma center. That probably saved his life even though there was a delay for the surgeon. It's good to read about atypical presentations so we don't get complacent and tunnel vision. My initial thought was he was having a massive ICH but if he was bleeding that much into his brain to cause the signs of shock that he had, he would have herniated already. I thought of a AAA after you mentioned the suprapubic ache but like you didn't think the signs fit. Good call following your gut feeling. Often our gut gives us the right answer when our brain tries to tell us otherwise. LS we don't know what this guy's "normal" glucose levels are. 205 could be low for him but more likely he had a surge in glucose from the catecholamine release with the shock. That's why trauma patients and critically ill patients have higher glucose levels. It would be more of a concern for a diabetic crisis if he was hypoglycemic. Good thinking along the lines of diabetic problems though as they could present very similarly and can mimic a stroke as well. Incredibly lucky guy!!! Lots of kudos to Herbie! Happy Thanksgiving all.

Not quite sure how to start with this... Not every patient who dies as a result of trauma dies from not being operated on fast enough. In the prehospital area you see the patient in the first few hours of severe trauma. You don't get to see the sequelae from the massive insults to the body. And not every patient is a candidate for surgery. How does surgery help pulmonary contusions, MODS, DIC, cerebral edema, fat emboli ...just to name a few of the actual causes of death of those who die within a few hours, days or even years post injury. Add to that, one single blood transfusion has risks and some of these people who have massive transfusions end up with complications caused by the transfusions alone on top of the trauma that the body is trying to deal with. A single episode of hypotension or hypoxia can also be an insult to a critically injured person that can increase their risk of death by a large percentage. (I don't have any of the studies at my fingertips but it's well documented). I'm too tired to really think of what I wanted to say here so I may come back to it tomorrow. Cheers!

You have to actually respond to 3 different text messages for the game to end. I didn't do quite as bad as I thought I was going to but still bad when you think about it. I was 0.16 seconds slower while texting but didn't miss any gates! Then again I am a female!!!!! (Couldn't resist! )

Oh well, guess I'm a whacker! (Been called much worse things! ). I have a helicopter decal with the words flight crew on the back of my car. I figure it saves the Chippie the effort of pulling out his/her ticket book and me the trouble of a ticket. Worked for me a couple of times! Cheers!

If it was increased ICP causing the exopthalmos then the fontanels should have been bulging or at least full. Usually raised ICP shouldn't affect the eyes unless there was some kind of defect or skull fracture that allowed fluid to communicate from the skull cavity into the orbital cavity. The 2 most likely diagnoses on my list are meningitis or NAT (non-accidental trauma) if you ignore the exopthalmos. He could have hydrocephalus but doesn't match either if the fontanel wasn't really full or bulging.

Check out Hand-Schuller-Christian Syndrome! Fits a lot of the symptoms.

Hmm, your comments made me think of something else. (I need to stop thinking here!) This is a TEENAGER and as no one saw what happened (and even if they did you can't trust their word) there is a high risk of a traumatic injury including spinal injury if he possibly was diving into the pool or slipped on the edge of it. You should use spinal precautions for any drowning victim even if friends say they weren't diving etc. I saw an episode of one of the reality shows where the friends all denied any kind of trauma with a drowning victim at the beach. He ended up with a devastating spinal injury and they HAD been playing around and hit his head on the bottom of the ocean and broke his neck. I dealt with a lot of pediatric drownings in the PICU in CA. Majority of the little ones rarely had spinal injuries but there was a few of the older ones who did from diving into pools and rivers, lakes etc. One kid hit his head on the side of the diving board and ended up with a spinal injury on top of the drowning. Besides a BB is a nice hard surface for doing CPR on if needed and a c-collar helps keep an airway aligned better (midline) and keeps an airway device more secure.

"Although it's clear ALS procedures were utilized in a significant percentage of patients, the authors didn't examine the medical records to determine whether they made a clinical difference. What was the impact on patient survival from cardiac arrest? I suspect there was none." So what the good Doctor is saying is that what is the point of ALS in cardiac arrest at all? Just transport them to the hospital fast? And if you are going to start training the BLS providers to do 12 leads without the ability to treat them then why not just make them all ALS providers instead?

Off duty and retired medics save Mayland [sic] teen. Kudos to these guys for a true save. I have a couple of questions for anyone who knows the area or more about the story since we know that we only get the grain of truth version in the media. Was it going to be much faster for them to put the kid in their POV and drive to the hospital than to wait for an ambulance? If you are going to get them there faster than the time it will take for an ambulance to arrive then good decision making. If, however, it is going to be a longer period of time for you to get to the hospital than for an ambulance to arrive at the scene you probably should wait for the ambulance to bring O2 and equipment to you. My concern with a drowning (or near drowning) is to get the oxygen to them without delay. If however, you are just down the street from the hospital it makes sense to bundle them up and take them yourself. Just wondering what the situation was here. That made me wonder if one of these guys actually had medical equipment (i.e. monitor or BP sphygmo. etc) and oxygen in their vehicles. (Otherwise how could they monitor vitals except RR and HR?). I don't know enough about the situation to make judgements but was just curious how many people carry this kind of stuff in their vehicles. I guess some of the supervisors and first responders would. Is it legal to carry stuff like O2 etc in your own vehicle without special authorization? I am really just curious. I have some first aid stuff in my car (mostly for camping) but no kind of medical equipment. If you do carry equipment that is not in your job description to have outside of the work environment what kind of legal ramifications would there be if you used them on a scene? Does it go outside of the good Samaritan law? Would you be setting yourself up for more trouble to have the equipment available (and are trained with it) and not use it or use it when it you are not on duty and not authorized to use it outside of work? Wonder which the lawyers would have more fun with? Any thoughts? I'm really just randomly thinking, wondering and philosophizing!!! Curious as to other's thoughts on the questions. Again, lots of kudos to these guys for saving this kid's life. The article just made me think about tangential questions and "what-if's". Cheers and hope everyone had a great 4th weekend.

Not being picky here but just as a note, almost a third of the air ambulance crashes in the last 5 years (fixed and rotor) have been airplanes. This is just the first one since 2007. They are all equal tragedies but the airplanes have a lot of the same problems as the helicopters with the majority of the causes being poor judgement and pilot error. Actual mechanical failures (like this one sounds like) don't account for as many as you would think. My condolences to family and friends of those lost in this latest tragedy.

I have to agree with Mateo here. You had improvements in his respiratory status with pt now able to speak in phrases to sentences. He had wheezing and good sats prior to this sudden distress caused by the onset of severe pain. He is now holding his breath, barely breathing because it hurts so much to even take little breaths, hence the increased resp rate, increased intrathoracic pressure because he is grunting from pain which is causing the JVD and decreased cardiac output. Since his asthma was improving it is not the major concern right now. His respiratory distress is currently related to his pain not his asthma. He needs to get his pain under control as much as possible as that is affecting his respiratory and cardiac status. If that means giving him the inhaled analgesics and arranging to meet the CCT for optional narcotics then that is what you need to do. I don't know what kind of inhaled analgesic setup you have but is there any way to add the nebulizer to the circuit like with an inline (ETT) nebulizer (McGyver it)? That way you can give both but you would have to be monitoring and titrating the analgesia pretty closely as it may affect the flow somewhat. Once you have given some pain medication and if his BP improves then I would consider giving some benzo's if you think he will tolerate it. This guy is on chronic high dose narcotics so he is going to be very tolerant of them. He needs very high doses of whatever you can give him to provide any relief. I think you can give him benzos once you see how his pressures hold without worrying too much about him dumping on you. The priority right now is to relax him enough to get him breathing appropriately and that will help the BP anyway. Anyway I think I just kept repeating myself so will leave it at that. Happy 4th weekend to all! Aussie.