fiznat

Could you mention a little more about this? How is the compensation achieved? RBC production?

No no, the body IS dealing with a lower oxygen saturation - because of the reduced atmospheric O2 as I described first - but also I was saying that I think the redirection of blood may ALSO play a factor as well. Then again I'm not sure of where the saturations were measured anyways, so it may not be a factor at all. The truth is though that these people do in fact have reduced oxygen saturation due to the reduced oxygen in the atmosphere. Nope you're right. The body does work on lower oxygen saturation, thats a major reason why climbing this high is such a great feat! These people go through the exhaustion of climbing, which is multiplied in intensity by the fact that it is difficult to breathe (and mantain any sort of saturation) up so high. You wouldnt catch me up there, no way! Youre also correct that the under reduced oxygen saturation, the body's production of energy -- ATP -- through the Kreb's cycle is slowed down. The Kreb's cycle is a process of producing energy using oxygen, called aerobic metabolsim. When the body is short on oxygen, it it is unable to use the Kreb's cycle and must use an anaerobic metabolsim (that is, "without oxygen"). The main producer of energy in this case is the process of glycolosis, which is basically the breakdown of sugars in order to produce energy. This method is WAY less efficient (something like 30 times less efficient) at producing ATP compared to the Kreb's cycle, and at the same time an offproduct of the cycle is lactic acid. This is what causes the burning sensation in your muscles when you are exerting yourself completely. Long term produciton of this acid causes problems in and of itself, not to mention the fact that you are producing less energy as well. Like I said, climbing is tough! Thanks man, that means alot!! :oops:

It seems to me that the low reading is probably coming from two things: First, cellular respiration (in this case referring to the transfer of oxygen and carbon dioxide on and off of the cell) is driven by a pressure (saturation) differential between the air within the lungs and the blood within the capillaries. Oxygen normally diffuses from the air to the blood because the air will have a reletavly high concentration of oxygen compared to the bloodstream. With one concentration high and the other low, oxygen transfers to obtain a balance between the two. The same works for the offloading of CO2, where the air in the lungs normally has a low content and the blood a high content, so CO2 tends to diffuse into the lungs. At high atmospheric pressures, the amount of ambient oxygen is reduced, so you end up with a smaller difference between the concentration of inhaled oxygen in the lungs, and oxygen in the blood. Because the amount of oxygen transferred depends directly on the difference of concentrations between these two areas, LESS oxygen is transferred to the blood-- which results in the decreased O2 saturation the doc was referring to. Second, oxygen saturation monitors depend on an assumption that the person being measured is perfusing blood to the extremity that is being measured. This doesnt necessairly happen in the cold. The body's natural response to cold and stress (both of which I imagine are in abundance up there on the mountian) is to shunt blood inwards towards the core of the body and away from the extremities. If the oxygen saturation was bieng measured on the fingers, it would be no suprise to see that the numbers would be lower simply due to the fact that there is less blood there. Hope this helps!

Diagnostic mode refers to the rate (measured in Hz) that the monitor is capturing the rhythm. Most LP12s are setup to use this mode automatically when doing 12 leads, but sometimes the setting is set for non-diagnostic for some reason. You can tell which mode you are in because the sampling rate is printed on the bottom of the strip. Usually diagnostic mode is around 75-150hz while non diagnosic is around 40hz. To change the setting on the LP12 you have to enter the main setup menu, which you get to by holding -- I forget which 2 buttons but they are the 2 above the HOME button -- as the machine is powering on. Some companies set an access code that you have to enter to get to this menu, often times (or by default, I'm not sure) the number is 0000. Hope that helps!

It seems to me that nurses should know better than to even ask for numbers like this. Yes, there are "normal" ranges for vital signs, but -as we all know- deviation outside of those norms isnt always cause for concern by itself. How about instead of providing these people with rigid, black and white objective guidelines, find a way to help educate them on the concept of "clinical presentation" instead.

Three or four things a paramedic can do that an I cannot? Is he serious? I cant believe this is coming out of the mouth of an EMS Medical Director. Talk about putting cost before patient care. That really is the ONLY reason I can imagine someone would say something like that. I really hope that EMS is organised enough over there to combat this effectivly.

...When on your approach to the scene, you see a first responder on his knees vomiting. Uh oh.

Ahhh I say tomato.... haha thanks for the clarification ER Doc.

I'm sure a lot of you guys know this already, but just to add to the discussion: Acetylcholine is mediated by another enzyme called Acetylcholinesterase, which serves the function of breaking down Acetylcholine. Like AZECP said, neurotransmitters like this do not metabolize as easially like many other chemicals do in the body, so this second enzyme is necessary to break it down when levels get too high. Organophosphates are potent neurotoxins because they work against Acetylcholinesterase. ...Meaning they destroy the enzyme that breaks down Acetylcholine, resulting in an excess of that neurotransmitter, and an increase of vagal stimulation. ...Hence the SLUDGE signs + symptoms, which are in effect the results of an overactive parasympathetic nervous system. We combat Organophosphate overdose with Atropine because, like Acetylcholinesterase, Atropine works to break down Acetylcholine and decrease parasympathetic tone. Learing about drugs on the cellular level is fun!

Interesting find! It is odd though that the problem is a physical hypertrophy and yet it is documented that only about 25% of cases present with electrocardiographic changes. Still, it seems like common presentations of this condition - while similar in nature - often dont tend to resolve on their own like they did in this patient. ...Not to mention also that this is extremely rare, effecting only .05-.2% of the population. Cool catch though. Dustyn, I agree with most both that this patient should be treated as ACS, and also that the patient is probably not suffering from ACS. Only other thing I can think to ask is if the pain - when the patient was having it - was reproducible or able to be made worse somehow. Even then though, it probably wouldnt change your approach to the treatment of this patient. I think MONA minus the M and N was perfect for this kind of "probably not" status post chest pain. Strong work though man, nice assessment.

As far as I know, "code" means "cardiac arrest." When we respond for a "code" we are responding to a patient who is pulseless and apenic (or at least thought to be). A patient who is "full code" means that he does NOT have a DNR order. Therefore, a patient who is "not a full code" could possibly mean that he is a DNR. Soo if I were dispatched to the "code (who is not a full code)" I would assume I was going to make a presumption of death. Another possability is that "code" is in reference to the type of response the ambulance was on. Code 1, Code 2, Code 3, etc meaning lights + sirens, lights, and no lights no sirens respectivly. Thats the only other thing I can think of.

Ahhhhh!! hahahaa! Zing! Thats great Dustyn haha... imagine your suprise to find out that Shane is on these boards too! lol... Nice one. Hahaha

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lol, history of a cabbage!!? Times four?!!? Four cabbages!? Thats a lot of cabbage for a lady her age dont you think? Hypercabbagemia I'd call it. CABG is the acronym, which stands for Coronary Artery Bypass Graft. Times four is probably not 4 years, but rather 4 vessles that were grafted. Sorry to be an a$$ about it but its simple misunderstandings like this that end up making EMS people look like complete morons to docs/nurses/patients. Your story is kinda hard to read, but I'm seeing basically a hypoxic CHF patient with the typical "maybe MI" S+S who gets vasodialators (two of them), and then drops her pressure to 90 systolic. A few things: -You probably forgot to mention it, but I didnt see anything about oxygen? O2 tends to help with hypoxia and PVCs. -You did a 12 lead so I assume you were thinking cardiac- what about ASA for her chest pain? Couldnt hurt with the a-fib as well. -Why do morphine before lasix? Seems like an odd order. In my system for CHFers we do O2, IV, NTG, Lasix, and maaybe MS... in that order. -Fluid bolus is contraindicated in patients with pulm. edema.

No doubt about that, man. Thanks for the comments guys. To answer a few questions, no we never got the oppertunity to get a blood pressure. The medic got 1 missed attempt at the airway while the monitor was going on, and once it was on and he saw the rhythm, then decided to cardiovert. I realise it is out of order for ABC... but we already attempted the ETT once by that point. Also, OPA + BVM was getting effective vents based on our lung sounds. I was going to hook up the NIBP but after we shocked there was significantly less need for it, heh... The crux of the question really is whether this patient needed cardioversion or not. Assume an ETT was already placed, a line in and running, and all the BLS is done. Would you cardiovert then? The question really is: in a patient who has a pulse but by all rights shouldnt, should we go in and start messing with rhythm issues? I'd be happy just to have a pulse, and at the carotid we know we have at least 70 systolic which is enough for CPP assuming no increased ICP. (this patient obviously had some significant ICP changes but still) Isnt that pretty damn good, considering we expected him to be pulseless?

We responded this past friday to a triple shooting. 3 kids in the ghetto all under 21. Our patient was a 16 year old male found on the sidewalk shot in the head and chest. Two other crews were taking the two other patients, so there was no triage issue. Our patient was shot directly in the forehead with brain matter visible, his whole forehead caved in from the force of the impact. The patient was also shot in the left side of the chest pectoral region. No visible exit wounds for either bullet. The patient had a distinct carotid pulse, tachy, not breathing. OPA placed, BVM ventilations. Board + collar and he was in the rig. I get the monitor on while the medic goes for the tube, which he is unable to get cause of blood continuing to fill the airway despite constant suction. With every BVM compression, air is forced through holes we now notice throughout the top of the kid's skull. Lung sounds with BVM are amazingly equal, although junky - presumably from blood. On the monitor the patient is in a wide complex tachycardia that we call VT. We still have pulses and my medic wants to cardiovert. We throw the pads on and hit him. Converted to PEA. The patient gets CPR and BVM enroute to the hospital. I drive. We are about 2 minutes away, my patch to the hospital is something along the lines of "Enroute to your facility ETA 2 minutes. Male patient young teens shot in the head and chest. Traumatic arrest. Was VT with a pulse, now PEA. Working on the ALS, we'll see you in 2 minutes." No time to get a tube or line enroute. On-scene time was 6 minutes, we are at the hospital within 2 minutes. We roll him into the trauma bay and the heads are already shaking no. The kid is obviously dead, but they work him for a few minutes anyways. They get a tube and call him. My medic confided in me that he wonders if he did the right thing. Specifically about the cardioversion. I told him yes, he did everything he could have possibly done and we did a great job - bieng as quick as we were. Still though, I'm not so sure. I mean, obvioulsy the point is mute with the type of injuries this kid had, but it is an interesting point nonetheless: did this trauma patient need cardioversion? We we taught in medic class that unstable VT needs cardioversion as it is an unstable rhythm. Still, this is trauma on a patient we expect to code any second. He is shot through the chest and once more in the head. I was happy we had pulses at all. If the situation were different, if he was in VF or something first and we shocked him, converting into VT with a pulse, we probably would have been happy to have that rhythm, right? I cant imagine that we would consider cardioversion at that point. This patient had a million things going on, with blood in the thorax, a bullet in the brain, and no airway. What do you guys think: should we have just been happy to have pulses, or did we do the right thing?

While I admit I dont know much about heart transplants, it seems reasonable to me that tachycardia could be a common problem with these patients being that they no longer have the ability to control heart rate through parasympathetic activity. Heart rate in these patients is completely controled by levels of sypmathetic tone, which in many cases can get extrememly high. Beta blockers would do their part to limit this sympathetic tone, thus controlling heart rate through the only system available to do so. Of course we always look at causes of a presenting problem, but often times these things are not all that obvious and we are resigned to treating only S+S. Beta blockers would serve well in this case.

Ah no big deal man. Its one of those detail things that you probably remember only while youre still in school. I've had my nose in the books for the past 11 months on this stuff so safe to say its pretty fresh in my mind haha. I'm sure theres plenty I could learn from your experience, as well.

I like to try and fix the simple things first if possible. Take the tape off of the IV and fiddle with it just a little bit-- you could have been up against a valve or something silly like that. Equally, triple check all of the IV tubing for kinks/locks. A trick I also like to do is take the line and wrap it tightly around my hand so that some fluid is forced through the line into the vein. Often that helps to clear out a line that has slowed down after sitting locked for a while. Also try rearranging your bag setup. Seems like a pretty weird valve/lock system you guys had goin there: high potential for screwups haha. Seems to me that if the 1000cc bag was shut off, it shouldnt be exerting any pressure on the line and therefore shouldnt be effecting the flow out of your 500cc bag at all. Screw it. I would probably just keep the #20 for meds, and start another line for fluid. Should probably have 2 lines anyways for someone about to give birth or undergo surgery whatever the case may be. Given that all of that fails, we *do* have a way of applying constant pressure to fluid bags in the ambulance-- a BP cuff! Wrap it around the bag and tighten it up, it works sweet. Also good for keeping fluid boluses going while moving the patient on a stretcher that doesnt have an IV pole. Just gotta remember to keep inflating the cuff as the volume of fluid in the bag gets depleted.

You're a little mixed up. Beta blockers are adrenergic antagonists, meaning yes they reduce sympathetic tone-- but not via the vagus nerve. The vagus nerve transmits parasympathetic activity, not sympathetic. You're right that the vagus is often disconnected during heart transplants, and your point IS a valid one when considering the use of anti-cholinergic drugs like Atropine, but its not the same case with beta blockers. 678, the medic you overheard might have made the same mistake. Like AZCEP said, Beta blockers should work just fine for these patients, unless we're missing something?

Wow, very nicely done! Where did you guys get the footage of all the accident/rescue stuff? Did you make it for this, or find it in archive? It came out awesome either way. Also, haha, nice KED job there!

12 lead EKG!!! What do you mean the previous EKG came back abnormal? What about it was abnormal? What did your 12 lead show? This information is pretty critical. I would have pressed the issue on the IV. Most people refuse IVs right away, but can be convinced. This patient needs one. Wheezes might have bought her a breathing treatment depending on the rest of her presentation. Peripheal edema, not a lot of fluid in the lungs and right sided chest pain all makes me worry about RVI. A 12 lead is necessary of course, but I most likely wouldnt be giving NTG to this patient anyways. What do you mean the paced rhythm was abnormal? Abnormal because it is paced or a paced rhythm that was also abnormal in some way? Also its interesting she has an allergy to sulfa drugs and yet she takes Lasix, which is a sulfa drug.

Pretty much just tight enough so that you get the flow rate you want. If you're squeezing the bag really tight and youre still not getting flow into the drip chamber, you should start thinking that something else is wrong with the IV line (clamped somewhere, blown, whatever). Too low and the fluid wont flow. Keep in mind you'll have to keep re-inflating the cuff as the volume in the bag gets depleted.

+1 for this idea. I've never done it myself but I have seen it done. Speaking of alternative uses for BP cuffs.. wrapping a cuff around your IV bag and inflating it makes a nice pressure bag so that fluid will still go in even when the bag isnt elevated. Works sweet for our service where we dont have poles on the stretchers.

lol, was it "uncle!!" heh, thats a pretty good idea. I like the concept of saving face for the student in front of the patient and also not letting the patient know that there is a problem with his/her care. Sucks though, to think that there will most likely be a time when I will be well over my head on a call that such a word would be necessary. I'm not arrogant enough to beleive that this couldnt happen-- but damn, I'm gonna do everything I can to try and make sure it doesnt. ...Another of my reasons for starting this thread and reading this this forum