DwayneEMTP

Still no signs of crackles in the lungs?

How come? What information are you going to give the doc to get him to approve the Lasix? What makes you say that? I'm kind of onboard with pulmonary edema but I'm also pretty confident that Biebs would recognize that if he heard it. Also we've got an elderly nursing home patient, tight lungs, hypertension, tachycardia, a captured run of PSVT..other than the distended neck veins, which may resolve to something liver related (I think), I think that there's a fair chance that this guy is going to get some fluid..And I'm really not looking at Lasix for him. But as always I tend to go looking for zebras, so my guess is that this is exactly what it appears to be..

I think that pulmonary edema is intuitive in this patient, but I don't see the signs of it. By the time that we're detecting wheezes we should be able to also pick ups crackles, yet they've not been reported in any region so far. I'm not really concerned about his hypertension where it is now, but Kiwi, why do you say that the Nitro will have no effect on that? And I think that I did address the tachycardia, but only briefly. I guess we'll have to wait for Biebs to come back and expound... Though I'm confident that Kiwi is right, that he's likely going to end up intubated, I'd still like to try and avoid it if possible, and the CPAP gives us a good option for doing so.

He can survive where he's at now for quite a while if he doesn't fatigue. I would hold off intubation if I think that he has the strength for it. Maybe chbare can chime in here as I can't really back up my belief that if I intubate him I've really retarded his chances of leaving the hospital as intact as before this crisis. I'm not nearly so concerned with adding an infection to an infection as the hospital is probably going to hose him down in IV antibiotics, but instead maintaining him and then trying to wean him from the vent. And I wouldn't trial the CPAP first, but possibly concurrently. It will help his issues as they are, but isn't likely, to my understanding, do anything to retard the bronchoconstriction that's being signaled by the wheezing, and I'm moving forward under the assumption that that's what's trying to kill him. I'm going to deliver the Mag Sulphate. Let put 2g in a 100 or 250 cc bag of saline and set it to run in the first half over the next 5 mins, and the second half over the next 10 mins and see what happens. With the newly developing wheezes I'm more confident with the mag, though it seems like there's something that I'm missing there. (but going to try and play it real. In this patient, with the information in my head, this is my decision.) Plus I wonder if we won't see some benefit for the run of tachycardia that we saw earlier? So, that's my decision. CPAP, O2 titrated to 95% SPO2, Mag 2g to start, over 10+ minutes, though may increase this if his pressure holds and it seems to be giving me a decent return on my investment. Also, I'm going to go ahead and push the steroids. What does anyone think about inhaled steroids or Epi for this guy? Screw physiological, from a psychological point of view it makes me feel better, and that's the important thing...

I think that at this point the I/O and intubation might be the least invasive, though we've not pushed the Epi. I know that that is a risky move with this patient, but I don't believe terribly so. The Epi may give us some more lung access which may give his heart a break. I wonder about some Mag in this patient? It doesn't sound as if the lungs are retarded secondary to matter but to constriction. I have no idea what kind of an idea this is for this patient. If she has his POA for medic decisions then I think that it's appropriate and ethical to explain that if we intubate his odds of being successfully removed from the vent at a later time are very questionable. Of course, if we don't, his odds of reaching the hospital alive are diminished. What kind of hospital will we reach in a half hour? Serious care, or bandaid station? I was on a call very much like this as a student. The patient was familiar to the medic, the daughter was adamant that her father would want to be allowed to die if he couldn't survive without invasive/pharmacological measures. She didn't have current paperwork but the medic and I loaded him into the ambulance, I bagged him until he died enroute to the ER. (And yeah, we reported the fact that he died in the ambulance.) Nothing else was done per the daughters wishes. If this daughter has the verifiable right to make life and death decisions for her father then no other decisions can really be made until she's completely informed to the best of our ability to do so.

The studies are a great idea! And we have clean water here. It's the men and women in the trucks and out in the mine that use the bottled water for the most part, and the expats that are afraid of drinking it... The problem with having them chart their urine is that they are afraid of making an issue of it and getting jammed up. So they will simply report whatever the manager tells them to in the morning. Plus it would be tough to get the mine to implement such a thing for 3,000 employee (those on site and those on break) as it would take materials and sit down education. Why sit down? Because everything needs a sit down education. And it pisses me off too. But it's not all indifference. Most everything medical here happens by tradition, superstition, or hearsay. So it's not, the best that I can understand at this time, a matter of, "Screw em, that should keep them from dying." So much as the managers also come from the lower altitudes and have the same belief that altitude is unimportant, that it's only heat and perspiration that are relevant. This is one of those examples of having to slowly change the culture in order to make an improvement. At a safety meeting the other day they got into a huge argument when the man presenting claimed that people's kids got sick because they didn't wash their hands enough, not from spirits and/or curses from their enemies. It was not an opinion that was well received...

Sorry, I probably edited that while you were posting... I've had urine dips on order for a few months without success, so it appears that that will not be an option.

That was my first idea too. The problem is that thought I tell management that there is no way that 600cc of fluid can be adequate for a grown man at this altitude on a 12hr shift, they claim that it's plenty for 'locals.' So I can't really attack them from that simple logic. I have to claim that it's not enough based on experience, but also support that it's not enough based on X findings...(yeah, urine dips have been ordered for months, so it appears that's not an option.) What would I have EMTB level providers track, that they can track reliably? I have no doubt at all that I can convince the people of this board that that this is an issue significant enough to act upon, but what to do to get a lower level of care to collect data that will convince the non medical decision makers?

So this is my issue... In the clinic here we see from 40-70 patients per day. It's been my belief, and my complaint here, that we see a comorbidity to URTIs, headache, body ache, etc secondary to relative dehydration in the majority of patients that we see. The management is not on board but claims that If I can track it and verify it that they will take it more seriously. The issues: Most of the workers here come from warmer, lower altitudes. We are at approximately 6,600ft with most workers working a 14-on/12-off day rotation. It is approximately 20 degrees cooler on average at this altitude than most are used to so they don't believe that staying hydrated is necessary because they are not normally sweating. The headaches, body aches, increased cough, darker urine is believed by nearly everyone local to be caused by the colder temperatures instead of hydration status. (I also noticed this in Afg. That a 'cool breeze' that can cause everything from influenza to cancer. Air conditioning was blamed for most everything.) Why I believe that it's an issue. Supervisors are required to provide water for their workers. But the most common story that I hear at the clinic is that workers are lined up at the beginning of shift and each is given one bottle (600cc) for the 12 hr day. I harp on the vollies that we train and have made hydration believers out of them. When doing pre training assessments on them the highest pulse rate that I've gotten (approx. 40 local nationals, mostly men, a few women) was 66 BPM. Their B/Ps tend to run in a pretty healthy range as well...130 (or below) over 80(or below). We've had a respiratory virus going around causing significant (though not normally dangerous) congestion of peoples lungs. I notice that the office workers (constant, easily accessible water) complain of productive cough, and L/S normally show rhonki, while those out in the mine complain of a harsher, non productive cough with normally diminished L/S. Office workers tend to have vitals within the range predicted by the vollies. Those in the field normally show in the high 70's to low 90's. But how to track this so that I can come up with numbers to make the point? I've seen it a million times, so I'm confident. Red eyes, elevated B/P, Pulse, headache, body aches, dry cough, etc.... What do you all think? Anyone had to do this before that's had a tried and true system? It has to be simple as the LN nurses will be recording most of it... I'd be grateful for your thoughts... Dwayne

It sounds like a three ambulance service looking to relocate posted by a member with English as a second language. Or spam...not sure which...

(Wait...you didn't do a refusal?..Heh..just kidding Brother. Inside joke for everyone else.) Percussion of the thoracic cavity? What does the ETCO2 look like? Any signs of trauma or abuse? What does the DNR state exactly? I considered a PE also but the coincidence of that coinciding with the mostly silent lungs seems pretty big. I'm also very skeptical of this being new onset. I'd be willing to bet that the nursing staff has no idea of the actual onset. Not bagging on the nurses. They can't be everywhere at once. Though I do hate the fact that I've never gotten a report from a nursing home nurse that said, "Last seen resting comfortable 4 hrs ago. Not sure of the onset." 25pts per nurse and yet they know what every single patient looked like 15 minutes ago? We need to get another IV, this time without using a tourniquet, though I would be curious to see if another IV would blow also. I can't remember what, but it seems like someone explained here once that thinning/delicate veins is a sign of something... Depending on the results of the Thoracic percussion I may have my partner set me up a half mg of Epi. Should the percussion return some hollow values then we need to consider decompressing this young fellow. After trying to r/o a pneumo let's gently bag in an Albuterol neb and see if that creates any air movement. How exhausted does this man look? Almost certainly a nasal intubation is going to be strongly considered. Is it possible that part of his respiratory rate and silent lung sounds is due to fatigue instead of completely caused by the primary pathology? His weight seems about right for his height for a healthy-ish patient, so chronic COPD bumps down a bit on my differential for a patient of this age. At least a severe chronic case. Top of my list right now is broncho constriction secondary to infection(?), spontaneous pneumo, though bilat seems unlikely, flash pulmonary edema, MI. One thing for sure is that I'm either going to get some air into this guy, or he's going to code right where he is. I'm not going to stress this critical patient by trying to move him until we can get him at least slightly improved. There's just no advantage in it that I can see other than CYA.

What do you want to bet that the results of the exams were all negative? One hero got freaked out about something, then another picked up his symptoms, then the others realized that two were sick and suddenly we had a whole squad with psychosomatic symptoms... Not saying that only because it's hosemonkeys..there was a case at a hospital not too long ago too I think...

Let's have basic vitals, then O2, sit him up straight if possible, send someone for a copy of the DNR. Not going to ask for everything so that others can participate too... Thanks Biebs...we've been needing some scenarios...

I get you Chris. My argument isn't based in logic nearly so much as personal bias. Fool me once, shame on you, fool me twice...man, I hate that. So it's more of a knee jerk reaction for me. I trusted it, it let me down, now I don't trust it any more. I think part of it too is that I'm not strong enough in ECGs any more to be able to read the computer interpretation without fearing having it drag me down an incorrect path that I'm not smart enough to think my way off of. I do read the time values often though. And that moment in the ER was certainly painful enough for me to be one trial learning. I abhor the thought now of saying, "This is my opinion on what's going on", hearing "What makes you say that?" and being left with, "Well, the machine said so..." I guess I'm not making the argument against using the machine interpretation so much as not considering it an ECG deity.

Because the machines are sometimes wrong. In the LP12 you can turn them off. I always did this at the start of shift secondary to taking a cardiac patient into the ER as a student and joyfully reading the machine interpretation to the 'big room' to find that it wasn't really very close. Not only that, but I knew as soon as I truly looked at the strip that I recognized it immediately and wouldn't have made such a mistake. But of course, I didn't look. Anyway, I think it's a good lesson for folks to learn that they need to use their own brain when possible. Just out of curiosity... Did any of the machine interpretations not match the human diagnosis on the strips? Chbare I certainly see your point but I've rarely, though it's been a few years since I've had to try as I've nothing so fancy here, seen them reliable enough to consider their interpretation. Perhaps your experience is different? I'm just so hinky about 'if it fails once out of 50, then I can't really trust it at all.' But again, the ECG I have now uses clamps on the arms and legs and brass bells with suction cups on them, so think might possibly have changed in the last little while..

Hey, can I ask how your question was answered? Not a trick question, or trying to set you up for anything, I swear. I'm just curious if someone answered in PM, and if so, why they cheated the rest of the group out of the answer? Curiosity only. Good to have you here my friend.. Dwayne

Brother I don't know if that was supposed to be funny or not, but it friggin' cracked me up! "So, you guys identify trolls here by those folks that ask too many medical questions all in a row?" Oh man, I love that.... You're doing fine man. On a regular basis people come here and pretend to be students, or medics, whatever, but are really posting stuff that they got from a dead family member, or their sister that got pissed at the medics that ran on her and are looking for information that might help them in a law suit. Recently we had a chick on here pretending to be a dying 16 year old girl. It's got folks a little bit froggy. If you're a phony I'm guessing that you're lawsuit would look something like, "You know, those fuckers misdiagnosed my mom, and she died! Just look at these ECGs! And before she was even cold they let some kid come in and practice intubating her! The indignity!" My apologies in advance for poking fun if you are a fake and that is actually what happened.... Dwayne

Remote duty paramedic, Hidden Valley, Papua New Guinea. Home, Colorado Springs, Colorado This is a really cool idea Biebs. If we can keep the thread halfway on track I'm really interested to see the results!

Good to have you back girl!! Hang around and play!

I'm not sure how I got it in my head that this was Biebs thread. But it's good still! And I'd not been aware that some hospitals had issues with such things...

Hey Jerry. My apologies for not responding. I'm not sure how I missed getting back to this thread. After your thorough and considered response I'll ask that you believe that there was no disrespect intended, but oversight only. I would tend to agree. Both fair reasons of course. But from the outside looking in it makes it difficult to give more than the considered, though uninformed opinion that I gave, and was asked for. Man, the NREMT CBT is disappointing to me on so many levels. Again, a fair question to which I'm afraid that I have no good answer. I guess I've gotten such a sour taste for programs that teach to the NR CBT that I lumped you into that category as it appeared, and I've not been completely disabused of the notion, that you can do little more in a program that's based online and has only 400 or so hrs of clinicals. (According to another poster.) But when I nearly enrolled in AMR's paramedic course they made the same claim. Their A&P was one hour/wk over 5 weeks. That's not really an A&P course, that really just teaching some folks some fancy words in case patients overhear them talking. Again, of course I'm not stating that you do likewise, but without further information that is the assumption that I've made. If not so terribly poor, at least not college level thorough. But again, that is my assumption, I've not heard that from anyone. I've taken another look at your site and I can't in any way defend myself against this question. I think that it's possible that I confused your site with another, or, again made a sweeping generalization based on comments such as this: "Get your EMT Basic Certification with just 10 days of live training." Can you truly say that that is a statement meant to attract those that are committed to a career in EMS? I don't believe that you can for the most part. Do I believe that you can turn out competent EMTs in 10 days of online training with some clinicals? I don't. I do apologize for my statements that you've quoted above. They were unfair and I can't defend them. I don't believe that at the time it was my intention to be unfair, but the result is that I've obviously been so regardless of my intentions. Sorry about that Brother. It's just a mixed bag for me. I sweat blood for 2 1/2 years and still didn't get the education that seem would be more appropriate for a paramedic. I'm certainly bigoted against the online courses, though you make it terribly hard for me to justify my bigotry. The bottom line for me, given some time and distance, is that Tony, and DEFIB (Who sometimes prefers his real name not be used here) are both more intelligent and more committed to the medical sciences than I am, have taken your courses, and both give them a gold star. That certainly speaks more loudly, and clearly than any bullshit opinion that I can develop based on a 15 minute perusal of your website or previous history with students from other programs. I hope that your program is all that you say it is. And if so I hope that it remains difficult and is massively successful. Thanks again, very much, for your response. While I don't apologize for my offered opinions, as they were developed and offered with honest and sincere intent in the context asked for, I certainly do apologize for the true misrepresentations. They were not fair, and I'd take them back if I could. Have a great day... Dwayne

I think that a minimum committment of time and energy should be necessary to stay involved at all, much less to be give the uniforms and such. It really pisses me off when people want stuff, but can't be bothered to earn it. I'd tell him that based on his attendance and participation record to date that he's not eligible for uniforms and/or pagers/radios, etc. Once he's show himself to be committed for 3 months then the issue can be revisited. That will likely be enough to send him on his way.