chbare

Indeed. So, we need to diagnose the overall disease and identify the specific causative organism. I appreciate the fact that you are holding back a bit. It looks like people are really thinking and researching this one. However, the scenario takes a crazy turn after we have a diagnosis.

It's a Wiki commons photograph. However, I have the ability to take my own photos of histology and bacterial samples via a microscope and flex camera. One of the benefits of being employed by a college. In fact, my paramedic students will be spending Monday in our physiology lab doing histology and an exercise in tonicity where they draw my blood, citrate it to prevent coagulation, then set up microscopic mounts and appreciate the RBC's as they add solutions of various tonicity. Unfortunately, I don't have any samples of the problem in this scenario. I'll give you a hint. The picture cannot be a Gram stain. You are not looking at bacteria per se, the ghostly blobs are red blood cells. However, the granular structures within the RBC at the bottom centre of the photo...

Actually, that's basically what I did. The patient was evacuated to a military hospital. However, let's say you feel like taking the new microscope for a diagnostic adventure. You do a blood smear and note the following:

Great discussion everybody. At this point I will tell you what we did and what occurred following our interventions: The physical exam this time is essentially unchanged. There are no other overt abnormalities on the X-ray. We went with a possible diagnosis of some sort of bacterial infection within the thorax: Pneumonia, Pneumonitis, Pleurisy and so on. The patient was given 1,000 mg of Tylenol and we started a peripheral IV. We gave the patient 2.5 mg of nebulised albuterol/salbutamol and gave the patient a 1,000 mg dose of ceftriaxone along with 1,000 ml of 0.9% saline IV. The patient improved dramatically a couple of hours later. We decided to let the patient go "home" on a rest profile with Tylenol and push fluids. We also loaded him with Zithromax 2,000 mg and discussed adding Levaquin in the event a resistant bacteria such as S. pneumoniae was the cause. Ultimately, we did not go with Levaquin. The patient was also ordered to follow up every 24 hours. If the patient was able to cough up any sputum, we would alos obtain a sample for a Gram stain + C&S. One of our physicians was involved with the case as well. After 24 hours, all appeared well. Then, the patient returned to the clinic at about the 36 hour mark with the exact same signs and symptoms. What to do?

No. Yes, but everything's frozen and Mosquitos are not out and about. He does IT work. Febrile antibodies are not going to be available. A new chest X-ray shows the development of a small right sided pleural effusion.

Zithromax is a macrolide. Do we have good evidence to begin anti microbial therapy however? He is sent home with APAP and push fluids instructions. A tentative diagnosis of viral syndrome is made. Unfortunately, he returns 48 hours later with the same symptoms. He also complains of chest tightness and you auscultate scattered wheezes. He is tachycardic, complains of generalised myalgia and a headache. His temperature is 102 F. Labs are back: He has leukocytosis and mild anaemia.

No rash. Why Augmentin? What does it cover, what do you suspect?

What Gram negative is suspected? What is a common cause of fever? Is is often bacterial or viral?

Why are we going with doxycycline? Is there enough evidence for us to empirically treat with a tetracycline? Your antimicrobial options include: Zithromax, ceftriaxone, Cipro, Bactrim DS, Augmentin, Levaquin, Amoxil and Ancef. Two hours after administering a gram of Tylenol and oral fluids, the patient reports that he is feeling much better. His fever has resolved and he is no longer tachycardic. What do you do? Labs will take at least two days to run.

However, you have a febrile patient to treat.

Stool characteristics are unremarkable. He does complain of a dull headache that comes and goes. (Off and on over the past week.) You can have your CBC in a couple of days. The febrile antibodies panel... Oh, yes he has been eating local foods.

Temp of 101.3 F, ECG: Sinus Tachycardia no ectopy or significant findings. You can send out basic labs. Let me know exactly what you want. Urine dipstick is negative for drugs. Edit: You do a portable chest and note an essentially normal film with areas of atelectasis to the bases bilaterally.

Awake, alert and oriented to all spheres, but appears anxious. Skin appears pale and the patient appears to be an obese, middle aged American male. Increased rate of breathing with no complaints of difficulty breathing. No lymphadenopathy is noted, no cyanosis, supple and midline trachea, no photophobia, ocular exam is unremarkable. Lung sounds are clear upper lobes bilat and diminished to the bases bilat without adventitious sounds. Complains of an occasional non-productive cough, no increased sputum production, no fremetus noted, resonate percussion notes noted. S1S2, tachycardia at 115 noted. No S/S of CHF appreciated. No GI complaints other than he doest feel like eating as much as usual. Abdominal exam is unremarkable, no urinary or GU complaints. PMHx: HTN, APPY, Lap Chole Meds: Takes Toprol XL but is not particularly compliant. You will have to send labs out unless you feel like running them your self. Let me know what you want to do. Good consideration. Patient lives in a modified railroad container and has had no exposure to smoke or hydrocarbon burning heaters.

Several states such as Nevada have an analogus credential for nurses.

You are a paramedic working at a remote clinic in Afghanistan. You are in the mountains and supporting a DOD project at a small airfield. It is late November with generally cold conditions and an evacuation off site would present with logistical and security challenges. A 48 year-old male presents to your clinic complaining of "feeling bad." Take it away. EDIT: Dwayne, your scenario privileges have been revoked on this one because you have insider knowledge on this patient.

Nurses are becoming much more interested in the pre-hospital environment. States are now developing pre-hospital nursing credentials for nurses who practice in the "field." The concept of the pre-hospital registered nurse (PHRN) is becoming much more popular. Also, many nurses who do this are not going through paramedic school to obtain these credentials. The nursing role in critical care ground transport has become so important, the Emergency Nurses Association developed a specialty certification for these nurses called certified transport registered nurse (CTRN).

First, I think this suicide business needs to be put into context: The human body is a biological organism that is entirely built around survival. In fact, it's only been the past several thousand years where we had creatures on this planet that have been able to really think and ponder concepts that do not directly stem from "survival instinct" if you will. We in health care, who are also scientists in a sense should be keenly aware of just how important survival is. It's built into our nervous systems, we see in in the ability to clot, we recoginse it when we undergo physiological changes at high altitudes, we see it in the physiology of our patients who are experiencing various forms of shock. With that said, when a person is at a place where they are essentially overiding millions of years of evolution and natural selection based around survival, this should be considered profoundly abnormal. I know many people simply look at suicide as being a sin or a profoundly selfish act. However, a person has to be profoundly disturbed to overcome basic survival programming. Unfortunately, we often do not really appreciate the absolute seriousness of a person who is suicidal. If we can appreciate suicide for what it is, then we can appreciate how desperate and profoundly sick these patients are or were. We clearly appreciate the gravity of the situation when a patient has severe DKA, but often fail to appreciate that with people who are suicidal. With all of that said, we should also realise that mental illness is not a problem with the "soul." It is a real, tangable and potentially devistating problem that requires aggressive treatment just like the DKA patient mentioned above. Even after initial treatment, this is often something that will not go away. Just like insulin dependant diabetes, we understand that a life long battle will ensue. Also, just like diabetes where even compliant patients can end up with serious exacerbations such as DKA, we can expect people who struggle with depression and suicidal thoughts/ideation and the like to also experiences exacerbations in spite of treatment. Religion is a tricky subject. While I believe it can play a positive role in some cases, we need to put religion in to proper context when considering the physical world. Religion is not a particularly good mechanism for exerting control over the physical world in the sense that things can magically occur as a result of divine intervention. I could be wrong, but have not appreciated evidence to suggest my hypothesis is incorrect. However, religion can play a significant role in people who can use it to help make sense of "life" and esoteric questions that cannot be answered by science. Religion can give us faith, hope and fellowship. These are all potentially important and helpful. Religion is a good way for like minded people to get together and support one and other and hopefully support others who are not as like minded, but that is another topic and another discussion. Clearly, this can become perniscious in some cases, but can be very helpful and supportive for some people. I see religion as playing a role in helping people in certain situations, but it cannot get in the way of therapy that is based on observation and emperic experience within the physical world. It may sound like I am an atheist; however, many here know that is not the case at all. With that, we cannot let our faith based ideas encroach upon the emperically derived physical world. My best wishes and thoughts go out to people who struggle with these issues because I gather the struggles can be difficult and are life long.

If you are not willing to throw down $500.00 for an iPad 2, hold out for the new Kindle Fire. It will only set you back $200.00 and has an amazing package of goodies to offer. While I absolutely love my iPad, the Fire looks to be a solid device with an impressive set of features. Not to mention the solid reputation of Amazon. Heck, even as an iPad user, most of my ebooks are read via the Kindle app and not through iBooks. http://www.youtube.com/watch?v=jZ29t8eHv4g&feature=youtube_gdata_player

It's a nitrate vasodilator. It has multiple FDA black box warnings. Precipitous changes in blood pressure can occur with it and at high doses cyanide toxicity can occur due to the development of cyanide like metabolites. Also, it must be reconstituted, mixed and stored with special precautions.

My bad, disregard my prior post.

By outline, you mean how to write the paper? APA format perhaps? I try to keep it simple and go with a 5 paragraph format when possible. A link to how to write a paper in APA format 101:

A significant consideration is the fact that we need to determine the extent, damages and processes that led to and resulted from the error. This is the reason we report errors and perform investigations and a root cause analysis. Going to a patient immediately following an error does no good as we often cannot provide the patient/family detailed information about the situation. Often, details and implications are not fully realised until the investigation phase. This is also why we have QI/QA processes in place, to identify issues and manage issues. In addition, many errors occur that are often unnoticed or unrecognised until the QI/QA process occurs and somebody identifies a potential issues. Also, how do we define an error and implications of said error? Technically, you could error by placing your chest pain patient on a non-rebreather at 15 LPM when said patient lacks dyspnea and have no signs or symptoms of hypoxaemia or hypoxia. Yet, many people are doing this. Should all of these "errors" be reported? Certain members of this site appear to lack basic understanding of the investigative process. it is less about "CYA" as some have put it and more about performing a good investigation in order to uncover as much information as possible, allow people to analyse and process said information, enable people to make plans of corrective action and allow people to assess the extent of damages. Often, this process leads to the identification of system wide issues that can be improved to prevent future problems. A medical error is not typically associated with a single event, but rather associated with a series of issues that all played a role in causing the error.

Agreed, no grey area for me in this scenario

In the case AK presented, no. I have already accepted care and have already initiated transport of this patient. The patient is on multiple, vasoactive medications. My primary task is to safely and expeditiously transport this patient to a facility where definitive care (presumably) will occur. I stop and my partner initiates patient contact, and now we are stuck and in both a legal and logistical mess. My bias is to avoid it and continue with the task at hand. Sorry for you if you are in that car, but that's my decision in this case. However, I appreciate other views, but I am not willing to complicate or compromise the primary task at hand. Especially, since there is a definitive legal and moral (IMHO) obligation to continue transporting my current patient.

Partner is a basic I believe? They cannot watch the patient. I'd keep going, but understand that will not sit well with others.