Aussieaid

Kind of interesting that all those spoofs are of paramedics "bashing" nurses and none the other way around. Take that for what it's worth....I'm just saying!

I just wanted to add my sympathies and prayers. I feel for you in your grief and am sending a big *cyber hug*.

Ok, there's so many things wrong with that story I don't know where to start..... First off unless you are doing CPR when they check the pulse it is impossible to have a pulse with "true" asystole. True asystole means there is no electrical activity happening in the heart and (unless you are artificially pumping the heart with CPR) the heart will not beat on it's own without an electrical impulse. So they either checked for a pulse while someone was doing CPR or there was something wrong with the monitor/s or leads or you are not getting the full story. Also you are not going to get a BP with asystole for the same reason. Next why are they treating a monitor? If you have a BP and a pulse why are they doing CPR? If the pt also sits up in between compressions and looks around that is usually a sign that he is perfusing something and not requiring CPR as well (unless it is some kind of post mortem or spinal reflex that was misinterpreted because I have heard of corpses sitting up because of the gas build up in them). You also can't pronounce someone with a pulse and a BP unless they are brain dead with lots of tests needing to be completed first. Some of the specific causes of cyanosis from the nipple line up are a hemopericardium, dissecting thoracic aortic aneurysm, traumatic asphyxiation and superior vena cava syndrome (or SVC syndrome). I am sure there are more but these are just some of the ones I could think of right now. It can also be seen with a non-traumatic cardiac arrest with no special significance attached to it. So I think there is either a lot more to this story or it has been twisted a little. Or something... If there is some interesting new condition to be learned about I am all ears and always open to learning more...

Es geht gut, danke aber ein bisschen langsam! Uh oh, Ich sollte das Wort nicht gesagt habe........ Spaeter!

Just want to clarify a point here Snoopy, not related to the issue of your partner fudging the vital signs (absolute shame on him!). Is it standard on these transports for the EMTs to take the vital signs? And why would he be giving report to the receiving staff when there are 2 RN's and possibly an MD and/or RT? Inquiring minds are wondering... Cheers and don't let YOUR standards fall,

Man, Phil! That video gave me chills (literally) and made me feel sick to my stomach even knowing the positive outcome! You would think after that one people would use the brakes on the prams. I am pretty sure majority of them have them. Also reinforces that you can't turn your back on your little ones for even a second. I can imagine that that Mum and the Grandma may need some PTSD help after that!

A lot of his symptoms sound like increased ICP whether from a stroke, meningitis or possibly cerebral edema it is unclear. The nausea, tinnitus, decreasing LOC and progressing to seizures sounds like a primary neurological condition probably complicated by the DKA which could be precipitated by the stress reaction and not taking his meds because he probably was already slightly altered. The big question is why is a 32 y/o on medications like metoprolol, lasix and lipitor. Sounds like he has some serious co-morbidities right there. Knowing more of his history would help give an idea of differential diagnoses. Lots of possible causes here but would need a lot more information. He could possibly be having a thyroid storm as well. I agree with Dave that the DKA was not treated very well. You really have to lower the glucose in a slow and controlled manner especially in someone who is already showing neurologic problems. I hope they didn't give him bicarb as well? The rapid rise in temperature after he was seizing could be as a result of the seizures, some infectious process (?meningitis) or thyroid storm. Would be interesting to see if you can get any follow up on him. I think the DKA was precipitated by something else and just added to the complications. Cheers.

Most of the time with propofol the problem is not the viscosity but the bubbles. You have to be really diligent about not shaking or tipping the bottle and running it through slowly so you don't get ANY air bubbles in it at all. The minimed hates any bubbles (often ones you can't even see) and propofol gets air bubbles really easily. Sometimes it is easier to draw it up in a syringe and prime the line that way. Gets less bubbles. Or the other problem might be that you are not venting the line. Using a vented spike helps. Do you open the little vent cap on the drip chamber? If you use a syringe it eliminates the need for venting as well. Just a suggestion since they often come in 50 ml bottles and you can draw it all up into a 60 ml syringe. Hope this helps anyway.

Airway 911 The RSI book on this page by Darren Braude is a really good easy to read and use book. It gives all the concepts and the drugs used as well. Written by an MD/EMT-P who is the medical director for PHI in New Mexico. I have a couple of other books as well but this one is the most concise, straight to the point and easy to read one. Cheers!

I know you really don't want to mess with the "Trauma Formula" but it really is stretching it to call 4 victims (3 of whom are dead) an MCI. I don't know SF's protocols but in the South Bay area they don't usually declare it an MCI until at least 5 patients. Mind you with the medical care given on the show they could say that they need mutual aid to deal with even one patient as it would exhaust their "local resources"!!! Cheers!

Honestly, with the media exposure and the "what could of happened" scenarios do you really think the crew will need "remedial training to lessen the chance of it happening again"???? I know if it was my mistake there is no chance it would ever happen again. I would be absolutely horrified that my "mistake" or moment of complacency could have killed someone and wouldn't forget it ever! I try to learn from other people's mistakes and as a result of this one I will be even more diligent in my "walk arounds" now. Better to learn from someone else's mistakes, I say. Life is too short to make them all myself!!! I am usually diligent anyway as I have heard of pieces of equipment or mechanic's tools being left where they shouldn't have been.

I totally agree with you Eydawn. The medical stuff is still a complete joke but the character development is coming along. And would you believe they didn't even have an MCI in the episode???? Some of the lines were a good insight into the world of and the people of EMS. It's not about the calls but about the people who do the calls!

She was just as much a victim. Yes, she was guilty of obstructing justice and she could possibly have prevented the crime (highly doubtful) but she had totally legitimate fear for her life also. This guy was obviously pyscho and abusive and proved he had no qualms about killing so she was totally justified in being afraid for her life. The control these abusers have over their victims is very hard to break and get away from. If you think she should pay in someway have no doubt that she probably is. She has to live with the aftermath of having been this guy's GF and the guilt that she didn't say or do anything for the rest of her life.

Want a challenge JP? Probably rarely seen in emergency medicine but possible.....what is JET? (That's how it is usually referred to as.)

To prevent dynamic hyperinflation (gas trapping) which can cause barotrauma and possibly a pneumothorax (including tension). If I have a kid with sinus arrhythmia how worried do I need to be? (Nice, easy one!) Nice thread, by the way, OP!

1) Paramedics have a different scope but not necessarily broader. For instance, how many can insert foleys, NGT's, titrate inotropes, infuse blood products, administer antibiotics, set up, start, run and discontinue dialysis (including CRRT), access central lines, insert PICC lines, initiate ventilator weaning protocols, manage invasive pacemakers, manage invasive monitoring lines (arterial, Swan Ganz etc)? Just to name a few "skills" beyond intubation. The majority of the aforementioned activities require some degree of "critical thinking" abilities. 2) If as a nurse you are unable to do this you won't last long in an intensive care or high acuity ER environment. Nurses don't stand around and wait for the doctor to come when a patient is coding. 3) Pretty bold statement to make based on hearsay and your own very minimal experience and limited knowledge. It actually only shows your ignorance of what it involves to be a nurse especially in a critical care unit or ER. I can guarantee you that there are many Doctors who have ignored a nurse's advice and caused harm to a patient or on the other hand listened to what a nurse said and prevented a serious event as a result. Do you think Doctors aren't human and don't make mistakes or write orders incorrectly? 4) Another example of ignorance since "educated clinical decision" making is the foundation of nursing. It is obvious that your whole perception of what a nurse is and does it to mindlessly follow Doctor's orders. 5) So following this philosophy I should not be able to be a Flight nurse as I was educated and trained in Australia? (Don't tell my bosses that, I have them bluffed!!! ) 6) I agree with Ventmedic about Paramedics having a false idea of autonomy. They all operate under standing orders or protocols (Doctor's orders! Every program has a Medical Director for that very reason). Many different units have their own version of standing orders and protocols just the same that nurses can initiate and use without having to ask the Doctor for each specific order. Autonomy exactly the same. The Doctors are not always readily available in the units either. How many medic programs have to call for online medical control to give an extra dose of Morphine over the protocol amount (just for example!). Really no difference just looking at it from a different perspective. Doctors orders and the protocols that paramedics follow are really the same thing except in the hospital they are individualized to a patient and not a broad disease category. Nurses in the ER will often triage and start treatment with standing orders before a doctor has even seen the pt. (For example with chest pain). Is that not exactly the same thing that a paramedic does? That is just one example. 7) Actually a midwife is a nurse with further education. You can't be a midwife without being a nurse first. I am not attacking you personally here. I am just a tad offended at the statements made when you obviously don't really know what you are talking about. Oh and p.s......Paramedics might be "creatures" but nurses aren't!!!

Just something to consider with the Torsades (polymorphic VT) she is probably hypomagnesemic along with the hypocalcemia. Ideally you would want some lab values but I think if she is being symptomatic with the episodes it would be reasonable to treat with a magnesium bolus. (It may also have secondary benefits of lowering the BP and helping the CHF from the fluid overload by some vasodilation), If they treat the hypocalcemia she would need some magnesium anyway. Just a thought.

Ok, I'll bite too... Although the majority of the MVCs I have been on have been related to DUI's (and there are laws regarding that ) I have been on quite a few elderly patients lately and I honestly don't know if they were at fault or not. The concern I have with the elderly driving (70+) is that not only is their hearing and vision impaired but the bigger problem is their reflexes. So even if they aren't at fault they just don't often react fast enough to avoid potential or actual hazards. The problem with the elderly is that when they are involved in accidents even a minor trauma becomes a major trauma and they do not have the compensatory mechanisms and healing capacity of younger folks so a hospital stay can be extended and have more negative outcomes than for younger people. So addressing the issue of whether they should drive or not is for their sakes as much as the rest of the population's. I agree with Dwayne that it isn't fair to just take all their rights away as they depend so much on the mobility they do have and we don't want to isolate them even more. Perhaps what is needed is restrictions such as already mentioned of no night time driving (young, healthy people's vision drastically deteriorates at night let alone what happens to the elderly), yearly vision, hearing AND reflex testing after a certain age (~70) and clearance by their Dr if they are on certain medications or have been diagnosed with certain conditions. In other words with conditions to driving and yearly re-evaluations. (and I'd be careful poking the Yeti, cause he might just take your whole hand off!)

I don't really have a strong opinion either way on wearing helmets in ground ambulances. I see both points of view. In saying that I always put my seatbelt on when I am in a ground ambulance and I can honestly say that I rarely see a ground crew member do the same in the back of the vehicle. I usually make my partner put theirs on as well. I understand the issue with not wearing it when doing CPR but really what percentage of the time on total calls are you actually doing CPR? Once you have completed a procedure make a habit of getting back in belt. It is not as effective but you can also put the seatbelt on and loosen it (I am not saying it should be done all the time) to complete procedures so at least you are not going to be thrown completely around the vehicle with sudden stops or in an accident. As soon as you have done what you need to do retighten your belt. I really liked the harness with the automatic recoil (I don't know the term for that!) that one ambulance had so you can lean forward and not have to worry about loosening and tightening belts. I am probably more conscious of the belts and helmets as they are standard in the helicopter. We have to keep our belts (and they are complete with bilateral shoulder harnesses not just lap belts) on all the time unless we are cleared out by the pilot. Then we do what we have to do and get back in belt as soon as possible. Rarely do we actually have to get out of belt but then we have a lot less room to maneuver around in in the aircraft and can easily reach mostly everything while in belts. Occasionally I will slip the shoulder straps off and loosen the lap belt but I rarely have to get completely out of belt. I wouldn't advocate for the full helmets such as we wear in the helicopters but even with those there is no procedure including CPR that cannot be done with a helmet on. We NEVER take our helmets off in flight and we have less room to do CPR in a helicopter than in an ambulance. (Actually it is a good thing to have the helmet then as it cushions the blows when your head is hitting the roof after each compression ). The other advantage to our helmets is the built in visor that means you no excuse for not wearing eye protection when you should be). Just thought I'd add in my 0.05 cents worth!

Just saying here...I am actually fairly comfortable with my knowledge base of ARDS, Sepsis and Ventilator management at my level. I answered the OP's questions at the prehospital level and with the limited treatment strategies available to a regular ALS crew. Now what they do in the ER and ICU is a whole other level that I wasn't even going to start on. I agree that aggressive suctioning is necessary especially with the aspiration and as he suctioned out about 200mls I don't think that he wasn't addressing this issue. However on the other hand the pt was cyanotic preintubation with no update on changes post intubation and no SpO2 readings given and it is going to be just as detrimental to the pt to keep suctioning too much and not allow the pt to recover or re-recruit ( just made that one up!) the collapsed alveoli. You know how long it can take to get someone's sats back up after just a couple of quick passes if they are really sick. Sometimes you have to trade off a little and allow them to recover even though they may still have more secretions. Sometimes you could hold a catheter down there continually and still not clear all the secretions. Watching how long some people take to suction out an ETT tube has made me hypoxic on many an occasion and I believe it is all about using appropriate judgment. Recruitment maneuvers in this case may only be as basic as not going overboard on the suctioning and allowing the lungs adequate time to re-expand to provide adequate oxygenation and by adding a reasonable level of PEEP (i.e. 10 cm H2O). If you fail to do at least some basic strategies prehospital to provide adequate oxygenation then significant irreversible brain damage may already have occurred and all the sophisticated treatments and strategies you apply in the hospital are not going to be able to fix it. PEEP may be one of the few tools that prehospital providers have available. Kind of hard to worry about ventilator strategies if all you have available is a DMR. With the sepsis the pt needs aggressive fluid resuscitation and it's ongoing which often leads to some pulmonary edema even before they are adequately resuscitated or inotropes are started. Add in the aspiration and with obviously sick lungs PEEP is going to be one of the fastest and most effective methods of oxygenating this pt. The PEEP is also used in conjunction with ongoing fluid resuscitation and inotropic support to provide adequate hemodynamic support. (Kind of why you often start inotropes when you start a kid on HFOV!) Anyway I probably shouldn't have reacted here but....I'm just saying, you know!

Agree with your pneumonia/sepsis possible diagnosis with aspiration on top of it. She is still dehydrated and needs the fluids but if she isn't responding well enough to just fluids she will need inotropes. Respiratory wise sounds like she could benefit from about 10 of PEEP right off the bat and use recruitment maneuvers when possible especially after suctioning. Try to minimize suctioning but it was obviously needed a lot. I will try to stop responding and let others give their thoughts.....

Start with a fluid bolus on a pressure infusor through the IO. Repeat as tolerated. I would probably give a couple of liters of fluid (multiple repeat boluses reassessing for response) before I went for an inotrope. If you have to start pressors and the fluid has not tanked her up enough to get an IV then I would put in a second IO for the pressor. Insert an NG tube if you have it. Start cooling measures. If her respiratory status starts to deteriorate with the fluids add PEEP. Just for starters.

I didn't say it was your mistake....I said learn from it. (A wise person learns from other people's mistakes as well as his own!) You said in the original post his BGL was 150 (now it is 183) which is already elevated and depending on the institution some places will initiate insulin therapy even at this level because hyperglycemia has been shown to increase mortality and morbidity whether it is caused by a stress response or from DM. Elevated glucose from stress response doesn't stay elevated forever either but it is still aggressively treated. Eventually the body may compensate but in the meantime there is still a state of hyperglycemia which is detrimental to the pt's overall well being and adding to the workload of an already overstressed body. The lesson to take from the case was don't be blase about any of the treatments we administer and technically this was a medication error that could have caused harm to the patient. (Something that would be hard to actually document though). Cheers.

Actually hyperglycemia has been shown to contribute to morbidity and mortality in many acute conditions, MI and CVAs being 2 of them. Multiple studies have shown that it can reduce hospital survival rates and glucose levels are often looked at as predictors of outcomes. Pt's are started on insulin drips to strictly control the glucose levels even when they are only slightly elevated no matter what the cause of the hyperglycemia. There are plenty of studies out there and it the adverse effects of hyperglycemia with head injuries and sepsis is also well documented. Here are just a couple of article to get you started: Controlling hyperglycemia in the hospital. hyperglycemia and MI Just learn from this mistake and remember that none of the treatments we administer are completely benign and all have some degree of risk associated with them. Cheers!

There is a strong possibility that she was actually septic and the dose of antibiotics caused a massive cytokine release resulting in her hypotension. In the very elderly they may not have a temperature and some of the other signs for you to pick up on the sepsis and she already has a known infection which may not have been as minor as was thought to be. Amoxicillin usually has a shorter half life than 6 hours but in the elderly a lot of drugs take longer to metabolize. She could also be hypotensive from septic shock where one dose of oral antibiotics has not been enough to halt the septic cascade. At the very least she needed to be taken to the ER for a full cardiac and septic work up. With her presentation I would not be having her self ambulate. Remember that things you can blow off in a younger person can be life threatening in a geriatric patient. Cheers, Gypsy.