Mateo_1387

Another update... http://www.latimes.com/local/lanow/la-me-ln-live-verdict-in-kelly-thomas-police-murder-case-20140113,0,5661959.story#axzz2qKI9CuI2

Seems like they need to go after the hospital for discharging him in an altered state. I really don't see how they security is to blame. And whoever the hospital staff is that expressed concerns.... they weren't advocating enough... I'm gonna see if I can get anymore info on this.... it happened fairly close by...

By chance is there a copy of the EKG that can be posted?

That was certainly an unkind thing for your friend to do. From reading your response, you seem to have a good grasp of how you want to handle the situation, by approaching her. It seems at the time of the original posting you were a bit emotional from the experience (which is expected, not to be taken as a fault). Sometimes it is okay to handle things while being emotional, as it certainly can add to whatever message you are trying to make (though should be reserved for certain circumstances probably). Otherwise, taking a step back and waiting until the brunt of the hard feelings passes gives you access to better tools you may use to handle a situation, such as logic and reasoning as Mikey said. Being a smooth operator in sticky situations will always make you the winner. Just sayin'... You asked what do you do... Well, what happened to you is an experience, and one that left you in a vulnerable position. To me, it seems this situation is one to store away and use to guide future encounters with your friend. It is up to you if you want to keep the friend's company, though if you do or do not, it is up to you to use this experience to keep from being stuck in the same situation. If you do get stuck in the same situation again, you'll get to claim your own asphalt. (ha, see what I did with that? Being left on the street... ah nevermind...) About you not being ready to do a ride along because you are an emotional 15 year old is true and false. Its easy for people to judge you based on age rather than character. Hell, it happens all the time with old folks. They say respect your elders, I say respect persons that deserve it, and base it off their qualities rather than physical age. Judging someone by their young age is not showing respect IMO. That is one of the real reasons you are probably not going to be able to do a ride along. The thing is right now you will just have to navigate the waters working against you. There is still much for you to learn (and most of us too, I suspect) but it seems to get easier and clearer in how you will handle these different situations. I think you show capability and maturity advanced of your physical age which is what the world needs to see in youth. Keep it up !

I have asked this question to a few people and I think I have two interesting answers, possibly worth using... 1st answer I liked was to just not ask, but bait the hospital staff to ask, cuz you know they will... haha 2nd answer from a friend of mine who is transgender states he don not know the best way to approach this situation. No help huh... Though he seemed to relay that just being polite and asking ought to be okay. Something along the lines of "no disrespect, are you male or female, I only ask to take your biology into consideration for a proper treatment plan". - As a side note my friend seemed to indicate he has encountered persons at work in which their gender orientation is difficult to determine. He said it is easier to avoid pronouns at times, otherwise, if you are comfortable (and maybe have to deal with persons longer than he may) to just ask their preference, respectfully of course.

Checking the NC procedures, pressure points are not specifically listed. That being said, it does not specifically prohibit it either. It uses language such as "control bleeding with standard technique" (saw this one on the tourniquet procedure page). Congratulations on passing the exam !

Levophed continued, support BP. For sedation probably just give Versed in small doses, 2 mg as needed for sedation. Probably hold off on the paralytic. As far as steroid, Methylprednisolone 125 mg to start with.

Welcome to the City from Eastern NC

With the patient's altered mental status and hypotension, I do not think CPAP would be the best intervention to perform. I know I mentioned pressure support on the ventilator, but thats with RSI and hypotension control. In her current state CPAP wouldn't be advised. I thought we would try a higher dose of Dopamine, or move on to Levophed? I think RSI would be warranted. Using Midazolam 2 mg, Succinylcholine 100 mg, pass the ET Tube and confirm. Its going to be important to control the blood pressure though. Looking at the labs (I'll be honest I had to look up a few values) I am not seeing anything spectacular. Glucose and BUN are elevated, the Hematocrit is slightly elevated. An NG tube and a Foley cath could also be organized. After RSI Albuterol may be administered to help with lower airway rhonchi/obstruction. Steroids may not be a bad idea either.

Thanks for the share, I like it !

I really like this !! Thanks for sharing Mobey.

I am thinking this patient may also have sepsis, possibly due to a pneumonia. The patient presents with Coarse left lung sounds along with diminished right lung sounds. If she is overdosed on narcotics, she is likely sedentary, breathing slowly, which I think would allow for bacterial growth and/or an aspiration pneumonia. After Naloxone is given thus reversing the effects of CNS depression, we see that she becomes tachycadic and has a slight raise in temperature. I think by this point it may also be prudent to start administering Dopamine. With her low perfusion status, end organ failure may be a real possibility, being we don't know how long she has been like this. Lets say we start out with the standard 5 mcg/kg/min, which at her weight of 150 (using a 1.6mg/mL Dopamine Concentration) would be 13 gtt/min. RSI may be an option, though I'd be weary of administering sedatives in lieu of the profound hypotension.

There have been LVAD patients in multiple districts I have been positioned in. I have never had the pleasure of interacting with one of these patients though. It was required for me to take a class about the LVAD, which consisted of a representative from the manufacturer, an RN I think, to give a lecture to us. It was quite informative. I will endeavor to relay that information to you, though suggest you confirm the information, as I really do not have a source for the information. Anyways here goes... When trouble shooting a problems, as others have echoed, and as the link Mike shared, use the family, call the coordinator, but be humble that you may not be the most knowledgeable about how the device works. Know though that a common alarm is a low flow alarm. Apparently, these patients often are dehydrated and may benefit from a fluid bolus. High blood viscosity can cause a low flow issue, thus fluids may help dilute the blood the promote circulation. There are three other "common issues" these patients may have along with the dehydration. Frequently LVAD patients are prone to stroke, Gastrointestinal Bleeds, and infection. I think some of these are self explanatory, such as stroke being due to the "thick" blood, probably clotting issues from trying to repair the surgical implants and permanent body openings (I'm really guess on this one, maybe someone else knows better than I). GI bleeds make sense to me as these patients will also be placed on anticoagulant therapy. Infection due to insertion site of the LVAD. As said before, no CPR.... But everything else can be done. These patients can receive all ACLS drugs and they may be defibrillated/cardioverted. Keep in mind theses patients have failing hearts and are usually waiting for a transplant. We were warned in class to not be surprised that a patient may present with things such as ventricular fibrillation and lethal heart rhythms, though are still able to communicate (though will likely be weak and have poor circulation). Also, keep in mind the patients are prone to have medical problems not related to the LVAD, so do not let it be a distraction during a differential workup. I hope this is helpful, I have tried to recall some of the more important information I remember from the class. It may be beneficial if your agency and local hospital (mostly emergency room staff) can put together a few classes with a representative from the LVAD community. Again, I suggest you confirm my information, as its not from a specific source, and some of the information may have changed by now, as I took the class a few years ago. If anyone knows better, please do not hesitate to correct me. I'd benefit from it too. Anyways, one last note, speaking of asking your coworker to take a blood pressure... I always enjoy going to a class and hearing someone say in reference to ventricular fibrillation "they won't be talking to you"... I usually comment back "well... if the patient has an LVAD, they might be talking to you".... Always looking for the exception to a rule... Matt

I am interested in knowing its significance too. Also, my interpretation of the EKG would depend if it is electrical alternans or not. I'm leaning between sinus tachycardia with electrical alternans, or sinus tachycardia with premature escape complexes, and I a few others. A-fib is one on the list, though this EKG sample has a pattern, every other complex group has the same R-R wave distance, leading me to think its not A-fib. So, what was the answer given with the sample?