fiznat

As promised, photos of the nebulizing BVM setup. Ingredients: -BVM/Mask -Nebulizing chamber with O2 tubing -T adapter -Male-to-male adapter I'm sure there is more than one way to put it all together, but this setup works nicely: Note that you will need TWO O2 sources. One for the BVM, and another to nebulize.

O/A Dispatched priority 1 for SOB. On arrival find 95 y/o female semi fowler's in bed on 2lpm n/c in significant respiratory distress. You notice a significantly increased work of breathing, tachypenia at 40rpm. She is alert and responsive, but baseline demented and hard of hearing. ...A poor historian at best who cannot fully answer your questions. She nods yes when asked about SOB, and will say not much else other than "hurry up, hurry up." The nursing home technicians (I now refuse to use the word "nurse" for these people. Call them NHTs.) state that there was an acute onset of these symptoms approxamately 1/2 hour before you arrived. This seems questionable because it was mentioned that the patient was only found in this condition because the NHT was coming into the same room for something else. So, unknown onset of symptoms but perhaps it was acute. Patient last seen normal 6 hours ago (this is in the middle of the night). The NHTs state that the patient is a new admit to them, and they are unfamiliar with the medical history. They "think" she has CHF, but they don't know. They are able to produce a list of medications, though, which helps: HX Rx: Lasix (20), Lopressor, Lorazepam, Ambien Hx: HTN/CHF, Dementia NKDA VS BP: 182/76 HR: 140 RR: 40, labored SPO2: 82% ETCO2: 59 Assess Alert, responsive. PEARRL. Skin very hot to touch/pink/dry. Lung sounds with harsh, rhonchi-sounds about all fields. Difficult to determine rhonchi vs rales but you lean towards rhonchi. Upper airway clear. No JVD, no distal edema. ABD soft/non-tender. Pt demonstrates +PMS/CSM x 4 extremities. Rapid trauma assessment is neg. for DCAPBTLS. Venous BGL is 96. EKG Tx Patient is sat up straight, placed on 15lpm NRB, IV established. Pt given 0.4mg NTG SL spray. Tpt --> ED. Enroute patient notes no change in SOB. SPO2 noted to increase to 100%, no other changes noted. Discuss I had a hard time making a decision as far as pneumonia vs. CHF with this patient. On one hand, the "acute onset," hypertension, and history seem to point to CHF. On the other, the hot skin, and probable rhonchi suggest pneumonia. I gave NTG only and held off on the Lasix because I was unsure. I thought briefly about a neb treatment, but I worried about giving beta-agonists to a tachycardic patient with ischemic changes. At the hospital they burnt off an I-Stat. I got a copy for you guys: (Here is a good website to help with reading ABGs: http://www.the-abg-site.com/about.htm) So yeah, hot skin for sure. 102.5 freakin degrees. Also looks like a compensated respiratory acidosis. ...Borderline metabolic acidosis there, though, as the HCO3 is at the very high end of normal (top range is 26). I wouldn't be surprised if there was a metabolic component to the acidosis as well, although who knows. The doc was pretty busy so I didn't get a chance to talk in depth with him about it, but it looked like they were leaning towards a pneumonia diagnosis. They sent off a BNP test to check, though, which I never got to see the results for. I will follow up if I can. Anyways, wondering what you guys think. Ask questions if I left anything out. Also let me know if the images are too big.

...and how was the pasta!??!?!

lol What about my pacing?

Before any of the above I would like to do the basic stuffs first. O2, Monitor, IV. Let's put her on 15lpm NRB with a basic airway adjunct if she will tolerate, Attach the monitor (including ETCO2, please?), and bang in an IV real quick. I'd like to know a few more quick history/assessment things (can do this while doing the basics) -Patient even been intubated due to asthma? -Did the MDI help at all? How many did she do? -Any pain, pressure, discomfort complaints before the change in mental status? -Recent illness, anything abnormal in this respect? -Whats that BGL? -Quick neuro checks (INCLUDING BABINSKI haha) -Rapid trauma assessment, focus on ABD (?AAA) and distal pulses if palpable (?equal) -Is this patient a full code? Probable first line actions: -Consider patency of the airway at GCS 5. Possible BVM? Think about intubation. -Shock precautions -Fluid blous 250cc for starters ...OR are you sticking by the "if you could do only 1 thing" question? If that is the case, I would really like to know that BGL first. ...Assuming it is normal of the choices above I think I would have to go with pacing. She is profoundly unstable, bradycardic and hypotensive. Although our protocols suggest a "brief trial of medication" prior to pacing (because if you have time to sedate you have time to try atropine), you say we can only pick one so there it is.

Pour Albuterol down the tube? Really? I've never heard of that or seen it done anywhere. Do your protocols allow that? I still don't know if this patient needs a tube. Simple bagging and a NPA brought some color back to this guy, saturations to just under 90%, and mental status returning. Tubing people brings with it such a host of other complexities and dangers, honestly I would try to avoid tubing this guy if it is at all possible. If just bagging brought him back this far, I imagine a little nebulised treatment and perhaps some epinephrine might make a world of difference. ...And not all purple people get tubed. If the hypoxia is secondary to an issue that can be treated right away (OD, hypoglycemia, sometimes asthma/COPD/CHFers, etc), I believe in the philosophy that it is best to avoid the intubation if possible. Let's also not forget that the guy wouldn't even take an OPA, so unless you've got some RSI or at least sedated intubation, you're not getting a tube regardless.

I don't know why it wouldn't be considered kosher. Docs around here have been nothing but supportive of the practice. I'm at work again on Friday, I'll set one of these bad boys up and take a few pics.

Consider this: your thread has been posed in the ALS forum for 5 days, and viewed just shy of 500 times by our members. In that time, not a single person has started to go down the path of reactive airway for this patient. I ask you to consider that perhaps this has more to do with the way the scenario was presented rather than some insufficiency on behalf of your readers. You are right that questions whether to intubate asthma patients, when to give epinephrine, etc are valid and interesting ones - IF we are certain that our patient is experiencing reactive airway. Thus far, I don't think many of us have been convinced of this. While it may have been obvious "in real life," as you say, it is not so clear here. THAT is why I asked for a more thorough neurological survey than you seem to have expected, because as far as I know: this patient is unconscious (or severely altered), and that alone may be the source of his pathology. It is worth a look. As far as doing airway stuff first, again, give me a break. You already said that a basic adjunct was placed, that the patient was being ventilated, and positioning had been changed. All of this, you said, lead to some color change and an increasing mental status. SPO2 came up to just shy of 90%. I don't see why BLS management of this airway wouldn't be fine until a more thorough ALS assessment is performed. ...And even still, this basic stuff should almost be assumed at this level. If we want to talk about drugs and intubation, let's give eachother the benefit of the doubt that we are able to comprehend basic airway management. You mentioned a "baseline level of respect?" As far as my understanding of the Babinski reflex, I believe I understand it well enough for the evaluation to be valid. I learned in school (not a google search, as you so rudely accused) that a positive Babinski test in patients over 2 years old indicates significant upper motor neurological damage which often carries with it a very poor prognosis. I remembered vaguely that often it was a structure called the pyramidal tracts (or system, as others have corrected) that was the source of the damage, but I admit I was not quite sure where the pyramidal tracts were or exactly what function (outside of motor control, obviously) they performed. I did do a quick search to validate that information, which I believe is reasonable. I in no way tried to pass this knowledge off on my own, in fact I TOLD you what came from Wikipedia-- this is how you know I got it there! I would hardly consider this arrogance, and - considering our depth of knowledge on many other subjects - I think my level of understanding on this subject is sufficient enough to perform this valuable exam. You mentioned that some shortcomings in knowledge are acceptable "in a 'need to know' kind of way." I propose that knowledge of the exact Babinksi pathology is not necessary for the test to be valuable in the field. It is not nuanced, as heart sounds can be, it is simple, easy, quick, and indicative of neurological damage that may otherwise lay hidden. It may not abruptly change our treatment modality, but it is part of a complete picture, and I think there is value in that other than simply trying to impress others. Perhaps our training is not as different as you say. Anyways, maybe we can get back to the scenario. Again, assuming this is indeed reactive airway, why cant you administer nebulised meds to a patient who is not intubated? Is this written in your protocol somewhere? You don't have to stop bagging a patient to administer a treatment, either. It is a bit of a funky setup, but a BVM and nebuliser chamber can be attached together in a way so that you bag in a treatment. I have done this before, and it works really well.

Sigh. The reason we check for neurological signs in an unconscious patient is to rule out factors that may be contributing to the entire presentation. Ever heard of an overdose? How about respiratory insufficiency secondary to any other pathology? (hint: this happens a lot). To find fault in the fact that I did not treat and assess airway issues before asking about neurological function on an internet posting board is pretty silly. OBVIOUSLY you deal with these things first. This is the ALS forum. Would you like me to walk you through positioning of the airway, inserting basic adjuncts, and ventilating? How about we go over how to plug the oxygen tubing to the D tank? BLS comes before ALS, of course, but get a grip. We assess, then treat. A full neurological exam, or at least a rapid field exam, would be absolutely appropriate in this case. Do we know if this patient is unconscious because he his hypoxic or hypoxic because he is unconscious? Obese patients have big problems maintaining their airways (and diaphragmatic pressures) when they are conscious and able to optimally position themselves, so imagine those issues compounded in someone who is unconscious. You say you could not hear lung sounds. Is this because of his size or because there is a pulmonary issue? How come he couldn't have stroked out and slumped himself into hypoxia? Why not a sugar problem, an overdose, a seizure, trauma, or cardiac? You seem to be ready to load this patient up with bronchodilators and epinephrine, and you haven't even done a complete assessment! Excuse me for my interest in being a little bit more thorough before we start throwing drugs around. To argue that I "don't understand" what plantar reflex means is tantamount to me saying that you might as well not check pupil response, or do a Cincinnati stroke scale because I doubt you could adequately detail the exact pathologies involved there, either. Can you tell me the cellular reactions that give nitro it's vasodilatory effect? Can you explain to anyone in true detail how adenosine causes it's nodal blocking? No, you cant. The reason you perform these tests, and the reason you give these drugs, is because someone who knows more than you told you that you should. You and I are paramedics, not doctors or medical scientists on any level. To say that I am not a good paramedic (or even a paramedic at all??) because my knowledge does not reach to the infinite details of cellular and neurological minituae is absolutely preposterous. It seems you would rather argue then talk about this patient anyways, so please feel free. *In response to other posters: I only brought up dystonic reaction because it seems the OP had confused it with something else. Although I admit we thus far know very little about this patient, I don't think any of us would think that this is a dystonic reaction. I referenced the pyramidal tract (or system?) because I believe this is typically one of the areas responsible for a pathological Babinski reflex.

Whatever dude, I'm not here to prove anything to you. You said you didn't know what it was so I told you as much as I know. I am a paramedic, not a neurologist, and while I cannot trace the pathology of plantar reflex for you to it's minituae, I can tell you without a doubt that it is a valuable finding, and an easy test to do, for any potentially neuro-compromised patient. If you don't feel it is necessary, and would rather not read about it, then honestly I really could give a shit. Every medic here, though, should know what a freaking extrapyramidal (AKA dystonic) reaction is. The fact that you confused this (with two names specifically excluding one from another!) doesn't bode well at all. Perhaps if you presented your "case study" (if that is even what this is) in a more organized and professional manner, you would get a few more serious supplies. When you openly mock a patient for his weight, then admit that you didn't even bring in any of your gear to the call, your credibility tends to slide down a few notches. Using childish name calling and references to penis size in response to a legitimate reply to your thread doesn't help either. Get over yourself.

haha thats funny, but comeon, why are they letting the guy stumble around, injuring himself and making a scene? Not to mention allowing someone to film the whole thing. Just bring the stretcher to him, sit the guy down, and get him outta there. Way too much screwing around imo. Almost a freakin' c-spine candidate after that hit there too, lol.

Yeahhh except this assumes that your company uses leads that come attached to eachother. Where I work the leads come in packages of 3 and loose. What we usually do is open up a bunch of packages and fill a specimen bag with the individual leads. If they came attached to eachother, that would be a different story.

I think you are confusing the pyramidal tract with extrapyramidal response. The first is one of the areas in which the babinski (plantar reflex) test checks for damage. It is a structure of upper motor neurons that I honestly know very little about, although I do know that positive babinski tests suggest neuro tissue damage that often coincides with a very poor prognosis. The extrapyramidal response, named so specifically to distinguish it as seperate from the pyramidal tract, refers to a neurological response arising outside of the pyramidal tract. Wikipedia tells me that this means the effector motor neurons are stimulated though indirect means in contrast to the pyramidal tract's more direct method. In any case, we often use the term "extrapyramidal response" to describe a common side effect of anti-psychotic drugs like Haldol. I'm sure you've seen it before: facial muscle rigidity, lip smacking, etc... treated with benadryl. I asked about babinksi only because I routinely do this on unresponsive patients in order to help evaluate neurological damage. It sounds like this patient would have been negative anyways. ETCO2 would do more than tell you hyper or hypocapenic, but if it is not available it is not available. Given what you've told us, I dont think I would want to intubate this guy until we get him extricated. It sounds like it is going to be a pretty rough ride out of the house on the tarp, and to be honest I wouldn't expect a tube to survive the trip. If it is going to take a while, I would instead plan to have a few regular pit-stops where the patient can be bagged, and then continued out of the house. Consider intubation afterwards, maybe. Does this patient have an in-home bipap machine or something similar? At that size, I wouldn't be surprised. I wonder if throwing that on, or perhaps your own cpap if you have it, would help. So how'd the extrication go?

I havn't found that the color of the MDI body correlates very well to the medicine inside, as the bodies are reusable while the medication itself is obviously not.. In any case, a google image search found this so maybe it'll help: It looked like the website it was from was written in spanish so perhaps that changes things...

Well there are a lot of things we'd want to know. As much history as possible, I suppose, but if that is unavailable: -Full set of vital signs -Lung sounds -Blood sugar -ETCO2 would be nice to really evaluate that breathing/perfusion/etc -Neuro checks (pupils, reactivity to painful stimuli, babinski, etc) -Physical exam. Is the purple color cyanosis or something else? etc etc etc Things I'd want to do: -Call for more resources and a supervisor. We've dealt with 500 pounders before at my company, and it took LOTS of help, including a huge tarp, to drag the people out of their homes. -Basic airway adjunct, NRB O2 or BVM if appropriate. -Remaining treatment guided by exam Need more info!

Yea, one of the things I never thought to bring along with me was entertainment for the many hours we would be sitting doing nothing. To be fair, though, we had no idea when we left that we would have so much free time. The guard guys had a good idea-- they set up a projector and watched a movie on one of the walls. That was pretty cool. Our division actually went out and bought frisbees and wiffleball stuff. We played a few games in the parking lot in front of the shelter. A competition or something like that would have been a cool idea, although I think if we stayed there much longer these things would have developed naturally. It takes a little while I think for a setup like this to get settled in, and it seems we were dismissed before that ever really happened. Next time, for sure.

Yup yup! Actually we did ambulance stocking also, so we probably crossed paths that day. Christy was helpful to us as well, although mostly apologetic at the overall lack of supplies. She asked me to make a list of what ALS stuff we were missing and when I was done, we both just kindof stared at the huge list and wondered if any of it would come in soon. We all did our best though, and it didn't turn out to be that bad. I wouldnt have seen you handing out the pink slips, we actually left early Wednesday morning (about 0500) from right in front of the place where we slept. We were never assigned vehicles or strike teams, so once most of the other teams had gone we took the leftovers and drove to Gulfport. Did you notice our AMR Hartford sign? haha

Not sure if you're looking for a simpler answer or not... high QRS voltage is shown on the EKG with very tall QRS waves. The displacement of those waves (height or depth) reflects the voltage detected, so abnormally high or deep waves indicate high voltage readings.

I just got back early this afternoon from FEMA deployment to Texas for hurricane Dean. We left early on Sunday and were dismissed on Wednesday when it no longer looked like the storm was going to touch Texas, and though we didn't get the chance to "see" anything, it was still a pretty interesting experience. The largest drill FEMA has ever conducted, so it turns out. We spent most of the time at Kelly air force base in San Antonio TX waiting for further instructions. There were a lot of numbers tossed around but the best turnout estimate I think was around 700 paramedics and EMTs, along with 350+ ambulances. At the Kelly staging area, all lined up and ready to go: Our accommodations at Kelly. Not exactly 5 star, but we made it work: The room there was much bigger than what you can see in the photo. To the right of the camera the room went on for quite a while- it was a big place packed with lots of people. FEMA did a pretty good job of getting resources into the area quickly. At first we thought we were all going to have to sleep on the floor but tons of cots and blankets arrived just in time: Also some of the local organizations put together various packages to sustain and entertain us. Among them was a fully stocked hygiene kit, and this collection of art supplies: Crayons, construction paper, pencils, ruler, and safety scissors. Awesome! haha We had lots of time to spare, so our group put together a little sign for our corner of the room: Sorry I don't have too many photos of the whole thing, we spent a lot of time indoors hanging out on our cots and talking with people from all over the country. It wasn't very photogenic, but we all met lots of very cool and interesting people who had driven ambulances from as far as California. The amount of people there and the necessary logistics must have been an absolutely massive undertaking, and even though the hurricane kept south, all in all it seemed FEMA did a decent job of handling everything. It wasn't smooth by any means, but I think everything would have worked well enough to be effective. We dove a convoy of ambulances from Texas to Gulfport MS before we flew out, driving through New Orleans and the surrounding areas affected by Katrina. It still looks really messed up down there, and while some of us were a little disappointed we didn't get to see any real "action" on this trip, I think everyone can thank god something like that didn't happen again. Did anyone else from this board go down there?

Protocols in my area have no allowance at all for RSI, or even sedated/assisted intubation. We are allowed to give 5mg Versed POST intubation, but that is it. All in all it is pretty weak, I think, and we are in need of a little more progressive protocols in this area. I admit I have only been a completely cut loose medic for about a month and a half now, but I personally have already had one or two patients for whom I would strongly consider RSI. It is used routinely in the hospital with excellent success, and with our availability of backup airways (Combitube and soon the LMA) I truly do not understand what the holdup is with this protocol. We are given standing orders for surgical airways, but not RSI? It doesn't make sense to me. A doc I recently explained this to, and who was unaware of our current protocols, was amazed to hear that we didnt have RSI. His quote: "So basically, either the patient is dead, or you're not going to be able to get the tube?" I'd like to think that our success rate is a little higher than that, but all in all it is kinda true. What is the holdup here.

That is an interesting EKG. I haven't seen a lot of these, but I think I would have a hard time activating a cath lab based on that strip alone. Does Sgarbossa's apply for paced rhythms? I have only found it in reference to LBBB. I wonder if things may be a little bit different if the axis is way off, as it is with this ventricularally-paced rhythm. There is concordance in V1-V3ish, but only because the direction of depolarization is altered due to the low (caudal) origin of the rhythm. The S wave should be prominent there, not the R. Is this still real concordance? I'm not trying to be sarcastic here, I'm asking because I dont know. Also there are no reciprocal changes at all, and the real height of the ST elevation may be confounded by retrograde atrial depolarization. There are a lot of things here that blur the image of true AMI. If activating the cath lab is such a stretch, an act of trust as 'Zilla mentioned, I really think I would have trouble making a firm decision on this one without a few other key findings. I'd be interested to hear what other people think. **Also, yes, EKG #2 was listed as the one with the AMI. *high five* :wink: #3, though, has some pretty tall (albeit discordant) elevations in the anterio-septal leads. Maybe close to the 5mm criteria?

I HATE this. It is the worst argument in the world, to say that we "dont have the money" to fund something as essential as EMS. Can you imagine if the same thing was said about funding for police? Or fire? Or public works? Or schools? Why is emergency medical service LAST on the list of these things to be considered essential? They don't have the money? Are you kidding?? FIND the money. This is important enough. EMS needs to be a municipality like fire and police. This would create better paying jobs with better benefits, which will increase competition for the job. Competition brings with it quality and respect. Let the private services keep doing transfers. Thats where they make their money, anyways. I really dont understand how this can be so clear to us working in the system, but apparently a mystery to those up on our respective capitol hills. We need a freaking lobby, already.

Ahh. Even still though I think I would recommend "B" based on the information given. It is a $7k pay difference, which is significant. Giving up that kind of money (plus added travel expenses) for the CHANCE of better calls is not worth it imo. Also keep in mind that you are a new EMT-I. I don't know how long you've worked as an EMT, but if you are new then any experience will be good for you. It wont be necessary to seek out the "worst" county available, since most of your experiences will be fruitful regardless. If you have plans to go elsewhere, seriously, I would just take the extra money and look towards the future.

I dont see the benefit to company A. It pays less, and is farther away. You say it is in a more urban environment but you also say that both places keep you busy. What's the decision here?

Okay I've found a few EKGs on my own. Let's discuss. Which of these would you guys call AMI using Sgarbossa's criteria? (Hint: only one of them, according to the website where I found them, is listed with a Dx of AMI.) (sorry for the large images) #1 #2 #3 **A question. Might spoil the answer for those interested in figuring it out for themselves:** What I dont understand about this criteria is that on the outset it seems to only be specific for certain areas of the EKG. ST elevations in concordance with the QRS requires a dominant R wave, which is normally only present in just a few of the chest leads (V4, V5, V6) and most of the limb leads. Unless there is some serious axis/rotational issue or wacky origin, the S wave is prominent in the other leads and we will never see ST "elevations" that are in concordance with what is normally a primarily negative QRS there. The criteria requires 5 millimeters of elevation in leads in which the QRS would be discordant. That seems like a pretty big MI. Does this mean that Sgarbossa is not very specific for anterior and septal AMI?