DwayneEMTP

Again firefighter, for about the 12th time... Did this person, with sats in the high 90's, show obvious signs of cyanosis? Did you actually read the scenario? Or are you just hell bent on ignorant tantrums? Dwayne

I agree completly Rid...My post wasn't aimed at you, I must have still been typing when you posted, so I didn't see your post until later. But, as someone else mentioned also...Would we expect to see the hypotension by the time this patient was cyanotic? Intuitively, I say no...that the pressure wouldn't be that great on the heart yet (Though I haven 't researched it) , or perhaps the hypotension would be secondary to hypoxia? Not sure. Did I bonehead the pulse s/s in the scenario? Dwayne

If this is in reference to firefighter and I...I'm all good. I have a feeling if we can someday pry firefighter away from his belief in 'absolutes' he's going to be first rate... I'm certainly not trying to tell you what to do, only to mention that I think I still have a lot to learn from this thread... Thanks for our great site! Dwayne

Ok, let's retract our claws for a sec and take a look at this thing. Lord knows I have plenty to learn here... First, did you read the part where this wasn't my call? That it was a scenario I was given? And had it actually been my call I would have boneheaded it terribly? How about decompression as a diagnostic aid? I may have stepped on my weenie here (Ok, if I could actually step on my weenie I probably wouldn't be trying to work for medic wages, but you know what I mean). I need to look into this further. If that was way off in the ditch, there was no vicious intent...It was simply a foolish thing to say, and I'll attempt to be more careful in the future. There were no answers that I was looking for. My goal was knowledge. I had no preconceived notions of what form that knowledge would come in. I'm not sure where this statement came from. If I have a tension pneumo, I hope you would decompress it. I don't have a lot of experience to argue with here. Do you have a ton of patients with cyanosis and sats in the 90's? I've had at least two patients with sats in the low 70's that were not cyanotic. Perhaps your experience has been different. Dwayne

You know, everyone told me after my rough start with my phase one clinicals that it wouldn't always be that way. Well, tonight I started phase two with a new medic and basic...and it was so good! When we were introduced, the medic said, (paraphrasing) “I don't really care where you're at in your clinicals, all the calls are yours. The scene, the patient, the decisions...this is your truck.” I said, “I'm not sure exactly what that means?” ( I was a little gunshy after my first preceptor). He said, “I want you to lead. You make whatever decisions you feel are best. If you're wrong, we'll help steer you right. If you miss something, we'll suggest it to you. If you get lost, we'll step in and take over until we can discuss it later, OK?” I said, “Ok.” And, God bless them, that is exactly what they did! First call, I grabbed the jump bag, went in and tried to run right over fire (Fire controls the scene and patient until released to the privates)...The medic touched me on the back, whispered “Step back, I'll explain later.” When the patient was delivered he explained that I had some things to learn about working together with fire, and I should follow his lead on scene until I got the hang of it. I wasn't an idiot, there was no yelling involved, simply a mistake that needed to be educated away. Cool as hell. I tech'd 13 calls, and tried to find the zebra on every one. At the end of each call I was expected to explain my rationale for each intervention or assessment direction, which I was thrilled to do as I'm not very confident in ANYTHING so far. On one call he said, “Why did you decide to do a 12 lead on a 90 y/o woman with shoulder pain and no history or other indications of cardiac issues?” I said, “Hell, you know what, I don't believe she needed a 12 lead...I was simply covering my ass.” :oops: He said, “With your experience, I think that was a very good decision.” Anyway, I could go on for pages...the difference in educational value with a good preceptor is so immense it's impossible to put into words. I was just reading Tskstorm's post, which is what made me think about posting this. Once again the 'council of elders' told me to keep the faith, so I did, because things would get better, and they did. Thank you all for the time you spend to teach and mentor those of us that so desperately need it. Have a great day all! Dwayne

I'm thinking that with lung sounds absent, and obvious cyanosis he's not moving much air, which I was taught was useful if you wanted decent returns on your albuterol investment. Also, I guess I missed the part in class where they explained pneumothorax as an indication for albuterol. I'll try and stay awake my next time through medic school. By the way, he's still dead. Dead. Dead. I'm glad you got all those things done. But you failed to mention decompression here....dead. I do like the way you think, and appreciate you pointing out the many possibilities for this patient. But for the sake of this scenario, it sounds like you guys were very efficient on your patient...but if your patient had been THIS patient...he would now be dead and unable to appreciate your impressive list of differentials and treatments. It doesn't really matter if you are completely correct on a lot of things if you're just a little bit wrong on this one thing....I'm just sayin'. Dwayne

Grin...No, didn't forget, I've just been running my tail off. I'm grateful for you spending the time to go through this..! I'm truly interested in this discussion, and it's rare we have someone fire side that is willing and able to have it. Don't give up yet! Have a great day Wayne. Dwayne

I'm not sure how soon you'd see cardiac effects from a pneumo, if ever, assuming we're talking pressure and not hypoxia of course. The lungs aren't really so much crushed, as made unable to inflate. The heart is working by a completely different set of physical principles.

You know what I think helps...though I'm not sure. When Barbara and I were first dating, she was a happy, vibrant, smart, funny person. This is the person I married. We decided then that it wasn't our job to make each other happy. It was our 'joy' to make each other happy, but when it became a job, to recognize something was broken, to either fix it, or it seemed all would be better served if we went out separate ways. Basically “If it doesn't work for you, I expect you to leave.” I helps me remember that she is not my property. I have to be the kind of person she'd pick TODAY. Because she's still smart, funny, sexy, and vibrant. She has options...I'd better make sure I'm smarter, funnier and kinder than the next guy if I don't want her to exercise those options! It's been my experience (Mom= 3 marriages, Dad= 4 marriages, Sister = 3-4 marriages (can't remember for sure) that after the honeymoon people start to believe they can “be themselves” and no longer have to be bothered being the person they were while dating. Hogwash. Anyway, I think my point is this: Young people seem to believe that a wedding ring is like a leash. You “have her now!” so she has to put up with your nonsense, laziness, rudeness...etc. Work today to be the person she'd pick TODAY, because that's where YOU find your greatest joy...and the rest is a cake walk...Because you know what? You DID NOT become "one" when you married. You started out as two very much whole and exciting people that decided to share your lives together. You were born and individual, she fell in love with an individual, you CHOSE to become a couple. Don't get all hinky after you get married. For the record...the above is my working theory...though I don't believe I'm nearly smart enough to have earned the amazing relationship I enjoy today...I'm just doing my best not to waste it. For some reason Barb seems to have made a terrible mistake in judgment regarding husband picking...I'm just going to enjoy it for all it's worth before she comes to her senses!!! I'm not trying to pretend to be smarter than others. It's just that you will have truckloads of people telling you how hard, stupid, pointless, frustrating, and impossible marriage is. I simply wanted you to have another perspective. Good luck to you! Dwayne

You go Eric! And don't worry about getting married... I hate it when people tell the younger folks "just remember, marriage is a lot of work!" Ah, bull. Marriage should be funny, nasty, silly, erotic, confusing, hilarious, sexy....and every now and then....it's a little work. If you find yourself spending more time working on your marriage than you're spending naked...You're doing it wrong! Good luck buddy...It'll be a hell of a ride!! Dwayne (22 years married...yep, to the same person, and all in a row)

I'm not sure I get what you're saying NRB...If the down time is too long then don't decompress? Dwayne

It didn't really here. The lack of audible breath sounds does not rule out the possibility of air movement, you simply couldn't hear it here. And there was not a lack of compliance with the bag as I would expect with FBAO, though I could be wrong I guess, just very poor compliance. It was explained to me like this. (after I tried epi...dead. Next time tried mag sulfate to attempt to loosen him up....dead. Dropped a tube...dead....gave him glucose ...dead, RSIed him ,(thinking maybe she was giving me some kind of seizure/lock jack/hypothermia/gonorrhea combo scenario)...dead, dead, dead. Kicked him, called his mother names...Still dead) Finally I attempted to decompress, simply because this was the only part of his body I hadn't broken, poked, poisoned, or damaged in some manner in previous scenarios. Medic :"You hear a loud hissssing, etc. Why didn't you do that sooner?" Me: "I didn't have a reasonable suspicion of a pneumo." Her: "Why? Tall, thin, little compliance to the bag. He's already mostly dead. What did you have to lose? By the way, I saved this patient. You killed him. All of them." Me: "Oh yeah! Well you're just a big smelly stupid head!!" (Yeah.....didn't really say that). Besides...I did save the last one... :oops: Anyway...should I run into this scenario in the future, I'm still not sure exactly what I should do, how I would verify it? (Hey! Percussion maybe? He should have sounded pretty dang hollow I'm thinking) But I was interested in everyone's thoughts. I'm happy that many of you much smarter than I went down the same logic path that I did...FBAO, asthma/anaphylaxis, laryngospasm, heart failure, etc. I'm not sure I'd even heard of an spontaneous pneumo before this... Anyway...have a great day all. I'd love to hear your experiences if you've dealt with this before... Dwayne

Hell...I'm actually on board with you this time AJ. I certainly did take the comment tongue in cheek, though I don't disagree with spenac calling him on it. It was meant to be funny, coming from a person that claims to honestly believe that all patients should be at least evaluated by EMS before the cops take control...So he gets my 'atta boy. There are some things at the City that are always going to get someone's back up. Be pro-volly or anti education, Dust is going to speak up, mistreat patients-spenac, make retard jokes-me. Obviously there are many, many others passionate about these same things, these are just the first that come to mind. It's a way of keep us all honest, no harm meant. Plus it's a way for us to get to know each other a little better, something that comes in handy when the topics really get hinky. You both have much to offer...let the criticism roll off when it doesn't apply...and let's keep on a learning curve here. Dwayne

There are no environmental causes involved here... You give somewhere between 0.5-1mg :wink: epi SQ. Your patient's heart rate increases to 220, shortly there after he codes, you follow ACLS protocols to the hospital but he remains dead... Yeah, same one. No noticeable lung sounds while ventilating. In fact, it seems that since achieving the tube, you have lost compliance. Bagging is becoming more difficult. The EMS God takes back the epi/trip to the hospital, and returns you to the living room floor... You notice (The medic says this should have been one of my first questions) that the patient is thin, and approx 6'6” tall.... This patient, assuming the medic gave me an honest call and a fair scenario, is savable. I truly do feel much better here. I was told in this scenario that one intervention should have been a no-brainer. I eventually got to it, but it was no where near the top of my list... What's next?

No time for BGL (But the EMS God tells me it isn't an issue), Skin and temp w/n/l for situation.

What Kaisu said....I had a full time job as well! I found it to be the most challenging thing I've ever done... For me the study time made the difference. 5 hrs/day on every day I didn't have class. 3 hrs plus class on class nights. No Exceptions! If I had to take an hour to go to my boys Parent/teacher conference, that time came out of my sleep schedule. Nothing was allowed to subtract from my study schedule. Had to work late? slept less, studied the same...You probably get it... And family, if you have a spouse/kids...Are vital. Make sure you are completely committed, not simply to finishing, but to excelling! (I think planning to excel actually made it easier, as it forced more rigid schedules, which tend to more regular, which allow you to acclimate (?) to them easier than a hurky jurky schedule put together on the fly). Good luck. Expect it to be difficult, but remember the pain doesn't last forever...but the benefit does. Dwayne

OK, I no longer feel like such a dork, I didn't think this was a slam dunk. I'm going to put (more or less) the above ideas together. Manual maneuvers (vs-eh?) = Abd thrusts I'd imagine? You apply abd thrusts to dislodge any physical blockage. After the first thrust, the patient becomes unresponsive. No food is dislodged, and visual inspection doesn't reveal an obstruction. An OPA is inserted, bagging is attempted, but there is little to no compliance to bagging. You decide to intubate. You easily visualize the tube passing the cords, the tube passes with no indication it's encountered an obstruction. Bag is attached, but there is very little compliance to bagging. Oh...LS...No sign of trauma or injury. Patient is completely unresponsive, extremely cyanotic, Nearest hospital is 15 mins away, you have all the help you want, what are you going to do? This patient is still salvageable!! Dwayne

Hell...Part of my post got eaten again...I will edit it to add it back into the original post. Sorry about that akroeze. Dwayne

A scenario given to me during clinicals, reported as a real call. There is very little information available, as I was told there was simply no time to collect it. Dispatched to DOB (difficulty of breathing) Dispatch informs you en route that the caller requested EMS due to DOB. Obvious respiratory anxiety on phone, 1-2 word dyspnea. While attempting to collect additional data the phone is dropped, line still open, and dispatch is unable to get the caller to return. U/a you find an approx. 45 y/o male supine on his living room floor. No sign of violence. Immediate impression is that this patient is Circling the Drain. No discernible lung sounds bilat, no wheezing/stridor, obvious extreme air hunger, cyanosis clearly present at lips, unable to speak, eyes panicked but tracking, PERRL, LOC steadily decreasing. Some diaphoresis, though not dramatic. Tachy @ 176. Unknown BP though pulse is strong and full. No history possible, no family/bystanders present. No medical jewelry or other info discovered. No sign of drugs, prescription or other. No indication of ETOH, apt is clean and well kept as is the patient. No ashtrays or other signs of tobacco use. I will give information as I can, as I was given it within the scenario. If the information requested is extensive, I will simply let you know that the patient died during is collection. I'm looking for THE necessary treatment(s)/intervention(s), not every possible treatment/intervention. For the record, I killed this patient about 6 times before I managed to save him... Again, this is a real call (I was told) you have only a few moments to offer the proper treatment(s)/intervention(s) to save the patient. What will you do? Also, if this scenario is obvious to you, as the medic claimed it should have been to me, please don't answer immediately so as to give others a chance to follow their own logic tree to an answer. Have a great day! Dwayne

You know what, even though perhaps in a quieter moment you might have worded things differently, I have great respect for your passion. My main question, and you can revisit the post it came from if you like, (I'm afraid I have to get some work done this morning so don't have time to try and redigest it all) is this: I did see where you mentioned (I think it was you) putting an ambulance in every fire house, though that still doesn't really answer the above question. As I reread this I can see where it might be misunderstood that I believe firemen are not important. That isn't the case. This question is brief and blunt to be clear, not to imply disrespect to the fire services. Have a great day Wayne. It's cool to see you back in this thread! Dwayne

I know what you mean. I'm no veteran of course, but in 150 or so sticks, I've never felt the "pop". But, as I stated earlier in this thread, I don't have the finest touch, so I'd imagine I'm simply missing it... Dwayne

You know Vent, you are a gift to the City. Your answers are so thorough, intelligent and educational. You often seem to intuit the unasked portions of a poster's questions...Pretty cool. Your kind of like a Dustdevil with girl parts and none of the rough edges... Thanks for the time you spend teaching us here. Dwayne

So are you then saying that hypoglycemia, stroke, overdose, hyperthermia, head injuries, and many more MEDICAL issues are also police matters? Or simply that the police are more qualified to assess these patients than you are? Unfortunately, you're showing why many people have a hard time respecting vollies. The above statement screams to me "Don't bother me with these difficult, yet non-glorious patients! Hell, it would be just my luck to miss getting on T.V. at a car crash while I'm screwing around with these Bozos!" (Aimed at the vollie stereotype, not all vollies in general) You're one of the most frustrating kinds of posters for me. You seem to be smart, even dedicated, yet you continue to make these types of statements. It's as if you're repeating nonsense that you heard somewhere, thought it sounded cool, yet didn't bother to run it through your own mental logic filter first. I truly look forward to the time that you become committed to one of these subjects, and we are exposed to your true, passionate, personal arguments. Dwayne Edited for typos, no content or context changes.

It's showing up in the window fine for me...Perhaps You didn't wait long enough for it to load? Dwayne

Those are certainly some of the worst jokes I've ever heard! But, seeing as how you had to be here to post them, I'll try and love 'em anyway! Barbara's favorite (I think) dorky joke? "What's Irish and sets on the back porch?" "Patty 'O furniture." Merry Christmas Michael, we've been missing you! Dwayne