chbare

MRSpykes, good thinking. Oxygen to increase tissue perfusion. Isotonic IV fluids will help with hydration, thinning out resp secretions, and can be used for meds. A bronchodilator may help open this guy up and may even help him cough and prevent further atelectasis. In addition it, may help him cough up a sputum sample for C & S testing. Need to get an X-ray to see where the pneumonia is located. From the history we suspect is is bilat lower lobe pneumonia. CBC will help us identify infection by looking at the WBC and the breakdown of the different white cells. A manual diff may be ordered as well. In addition, blood cultures may be ordered as well. This guy will be put on ABO's. Depending on his status in the ER, he may be admitted and receive IV ABO's. The docs down here like the shot gun approach until the C&S comes back. IV Levaquin and Rocephin. Tylenol could be given for the fever. A cardiac profile and 12 lead may be ordered as well. (Age, risk factors, and a pulmonary C/O.) Take care, chbare.

MrSpykes, the diagnosis of pneumonia is correct. The findings of a productive green cough, fever, abnormal lung sounds, malaise, dyspnea, and fremitus are highly suggestive of pneumonia. Lets take it a step further? How would we treat this guy enroute to the hospital? Then, what tests do you expect to be ordered while at the hospital? Next, how will we help this guy get better? Finally, let us back our responses up with a rationale. Take care, chbare.

Ok, here goes. Let us start with an easy one. You are dispatched to the residence of a 52 year old male who complains of dyspnea. Upon arrival you find a safe scene without any noticeable hazards. S: 52 Y/O male complains of frequent productive coughing over the past week with generalized malaise and states "I am having a hard time catching my breath." States coughing up green sputum. A-NKDA, M-Tylenol po prn, PMHX-Appy 1990, T&A 1960, Smoker 1PPD/30 years, Occasional drinker, Denies drug use, L- a power bar this am, E- "started with productive cough 7 days ago, slowly been feeling worse with more coughing, unable to catch my breath, and generalized weakness." O-7 days ago, P-Activity, Q-"Weak, tired, and cannot catch my breath." R- N/A, S- "I have never been short of breath like this" T- "Started 7 days ago." Height~5'7" Weight~215# O: General Impression, AO*4, Ambulatory with MAE and steady gait. Frequent cough noted, coughing up greenish sputum. V/S: P-117 Strong & Regular, RR- 24 Moderate Dyspnea with Productive Coughing, SA02-88% R/A, B/P- 146/092, Temp- 101.2 F. Neuro: No deficits noted, unremarkable. Psych: Anxious. HEENT: Unremarkable exam with the exception of the patient coughing up greenish sputum. CV: Regular apical pulse equal to radial without any deficits or abnormalities noted. Sinus tachycardia noted on the monitor in lead II. CX: Wheezing noted throughout all lobes with fremitus to the bases during the palpation exam. ABD: Unremarkable, normal bowel habits noted. GU: Unremarkable. Back: Unremarkable. EXT: Unremarkable. Integ: Pale skin noted with flushing around the face and neck. A: ????? P: ????? E: ????? Take care, chbare.

Ridryder911, that is too bad. I thought LPN education was more college level, I am disappointed to hear that there are still many vocational type programs. (I really thought this was phasing out) Most of the LPN's that I work with have a year of college under their belt, then again, it is a big country. I wish people could see that you can train anybody to do anything, but education is a different animal. That is the beauty of professional education programs. (MD, RN, etc.) (*Good professional education programs.) You are educated first, then after you are educated and have a solid foundation, you can receive that training in skills and procedures. In any event, this has gotten way off topic. Regardless of my feelings toward EMT-I training, I cannot deny that passing EMT-I/99 is an achievement, and I am quite sure that Rezq304 has worked hard. I do wish Rezq304 all of the luck in the world on passing the written exam. Take care, chbare.

JPINFV, that is a good way to break it down. Just remember that NP's, CNS's, and CRNA's are all considered RN's. They, however, in most cases are RN's educated well beyond the initial RN degree. (Master's level education) In some cases mid level providers (NP's) may practice without direct physician supervision. Ridryder911 may very well have more knowledge than most on advanced practice nurses because of his unique position. How much longer now, Ridryder911? :wink: Take care, chbare.

Ridryder 911, I guess I stand corrected. All of the LPN programs that I have known were college level. Then again, I only know those programs specific to my area of the country. brock8024, it looks like you can disregard my prior post. :oops: Take care, chbare.

Brock8024, I do not think you can use the LPN and RN comparison. The LPN is educated and does know the reasoning, pathophysiology, and implications of the procedures that they perform. Generally LPN's will have 1-2 years of education and complete the same general requisite studies that the RN must complete. (A&P, math, biology, English, and psych among other courses) The LPN must sit on a board, (NCLEX PN) and is considered a licensed health care provider. True, the RN does receive additional education and will generally work in a leadership role. It is also true that RN's are generally responsible for performing additional invasive procedures. (hanging blood, IV medications, IV access depending on the facility) However, I do not think the comparison is valid. Take care, chbare.

This is how the poll is going at fieldmedics.com. Total of 10 votes. There are polls on other websites as well. (trauma central and ems village) However, EMT city and fieldmedics have the only polls with 10 or more votes. It would be interesting to compare the data if more people voted. 1) 20% [2] 2) 30% [3] 3) 20% [2] 4) 20% [2] 5) 10% [1] Take care, chbare.

Jdewit, welcome to the city. I cannot speak for the level of providers in South Africa, however, I can give you some basic information on the EMT-B in the USA. Most EMT programs are based around a 110 hour curriculum. The training focuses on BLS skills and knowledge. The specific scope of practice seems to vary greatly from place to place. Generally EMT-B's are allowed to insert airway adjuncts, suction, perform BLS and utilize the AED. In some areas basics can place rescue airways and intubate. They are also trained to stop bleeding, splint, and touch on the basics of medical,trauma, psych, environmental, and OB/GYN/Pediatric emergencies. Invasive procedures and pharmacology vary but many EMT-B's are allowed to administer a few medications. In addition, EMT-B's learn a little about patient assessment, documentation, anatomy, moving patients, and HAZMAT. EMT-B's may work as the sole provider or with an EMT-I/P team depending on where they work. I cannot recommend that you take an entire EMT-B course if you just wish to learn first aid skills. As far as life saving, I am not sure any human being can actually take credit for saving a life. (more playing a role in some kind of master plan) However, I will keep my personal views out of this post. I hope this helps. Take care, chbare.

I still like the good old waterproof booklet. Call me old school, but I have had terrible luck with anything electronic. My field guide never crashes, runs low on power, or breaks if dropped or exposed to the elements. True, you can up grade the PDA, but the good old permanent marker works well for me. In addition, the guide is more of a quick double check reference, not something that I use in place of a good understanding of medications, procedures, and patient care. However, other people I work with love their PDA and have not experienced the problems that I did. Take care, chbare.

35% Dixie. You are definitely a Yankee. Take care, chbare.

Traumatizer1, yes it carries oxygen. Take care, chbare.

6 - 10 = You are getting older Take care, chbare.

Brutal on the "care a bear comments." AZCEP, I know the term craniocervical cyanosis is used to describe the discoloring of the face and head in the traumatic asphyxia patient. It may also be a way of describing "hooding." Take care, chbare.

I am glad everybody liked this scenario. I hope people have noticed a trend in my last few scenarios. I am trying to get people to use good assessment and history taking skills/techniques. This scenario could be solved using only BLS skills with good assessment techniques. I want to help people see that the power of knowledge and an appreciation for pathophyisology is just as important if not more than all of the cool guy ALS skills. As an EMT-B you may not be able to put in an IV or perform intubation. Your care is limited to BLS, however, your knowledge of patient assessment and pathology can be limitless. Take care, chbare.

Nate, 0700 shift change. New crew will arrive between 0645-0700. Take care, chbare.

SOAPE S/O: What is her LOC? Quickly assess the ABC's and ensure her hemodynamic status is intact. Obtain a set of baseline vital signs to include pulse ox and skin assessment along with tilt testing. Lung sounds, ABD assessment, and focused neuro assessment/HEENT exam. 12 Cranial nerve exam and focused eye exam. ROM and strength assessment of extremities. BGL? Rule out carbon monoxide poisoning if possible. Obtain history of present illness and PMHX. SAMPLE & OPQRST A: Based on the history and physical exam. P: supplemental o2 cardiac monitor and 12 lead vascular access transport after detailed exam is finished E: ongoing assessments I will have a few things to consider in the ER based on the findings above. Take care, chbare.

AZCEP, I would think cyanosis could be present. I guess that this patient was compensating well given the serious nature of his condition. Edit: Rocket, you are welcome. Take care, chbare.

MedicRN, you nailed it. He has a ruptured septum. This was a complication of his MI. Here are some links for additional information on this problem. Managing his hemodynamic status will be a nightmare until we can repair the defect. http://cardiacsurgery.ctsnetbooks.org/cgi/.../681?ck=nck#R31 http://www.emedicine.com/med/topic3574.htm Take care, chbare.

AZCEP; Chest X ray indicates pulmonary edema with properly placed ETT. Foley is in with very little output. EtCo2=19. Ahhh, nice call on the echo. Here you go. Please note that if you look at the apex all you can see is black. If you bring the doppler down a little the apex is visible. However the bright colored divider between the right and left ventricle remains open about half way down. Left ventricular ejection fraction is.....not good. Dopamine is started. What do you think now? Take care, chbare.

AZCEP, you are correct. CPAP was a good idea while the patient was awake, however, he now requires more aggressive airway management. (yes I know CPAP is used for sleep apnea) Intubated with 8.0 ETT and on vent with whatever setting you like. Placement confirmed. ABG machine just went down. It seems bio med is moonlighting for Never Never Land and has been slack on maintenance in the Land of OZ. Radiology states he cannot do a CT because you do not have a BUN and CREAT. Is there a less invasive test you could consider? Take care, chbare.

AZCEP, the rhythm is sinus tachycardia with the occasional unifocal PVC and borderline 1st degree AV block. Further evalution of the ECG will not really help with the diagnosis. The very poor R wave progression may help. Radial pulses are equal bilat. You can palpate bilat pedal pulses. Co2 is 22. No carotid bruits noted, however, you can hear a loud harsh systolic murmur. Rocket, your in the land of OZ. What you want is what you get! The patient is now very lethargic, only reaponds to a sternal rub. He is very pale and diaphoretic with a systolic pressure of 70/P. His RR is 33 and shallow with a SAO2 of 87% on NRB. Pulse is 128 and very weak. Take care, chbare.

Medic429 & AZCEP; - + JVD. - Lung sounds; coarse crackles to the bases bilat. (you note very harsh sounds at a rate of about 110 when listening over the left anterior chest for lung sounds) - 1+ bilat pedal pitting edema. -Abd soft and non tender. -O2 15 LPM via NRB---> Remains pale and diaphoretic, continues to C/O dyspnea, SAO2- 93%. -BGL 142 mg/dl -12 Lead shows Q waves in leads V1-V4 (old infarct?) with very poor R wave progression and some non specific ST changes in V1-V4. -IV access is obtained. -Transport is 25 minutes. Anything else? Take care, chbare.

MedicRN & Hammerpcp; -The pain started suddenly at 21:30 it is now 22:00. -He was sitting down watching the television. -He states he had a heart attack 6 days ago and was discharged from the hospital yesterday. -The pain is located over his heart and radiates into the substernal area. He states it is hard to describe it, but "it feels very different from his heart attack and he just does not feel good at all." -He does have NTG tablets but misplaced them. -He misplaced his meds as well, but states he takes a blood pressure/heart pill and an aspirin every day. -No history of trauma noted. -Pulse: 110 weak slightly irreg at the radial. RR: 22-24 moderately labored. B/P: 88/46. SAO2: 90% on room air. Pain: 9/10. Skin: pale and starting to look diaphoretic. Take care, chbare.

AZCEP, Quiet night in the neighborhood, nothing out of place. Patient is found sitting up in bed. Patient is AO times 4, he looks pale, and complains of chest pain and tightness with dyspnea. His ariway is patient and he is breathing at about 24 times a minute. Take care, chbare.