1EMT-P

The above mentioned patient had an extensive history, including a cardiac history, history of hypertension and a history of subarachnoid hemorrhage. She was feeling bad enough that she went to see her PCP who determined that she was experiencing a " Hypertensive Crises" based upon her systolic blood pressure, physical exam and her signs and symptoms. The following tests were completed in the office 1. Blood glucose which was 98, 2. Urine Analysis which showed protein in the urine. 3. Ekg which showed a Sinus Rhythmn with PVC's rate 90. The nursing staff started an IV of NS in the left AC with a #20 gauge. Started the patient on 4 LPM of Oxygen by Nasal Cannula. They also gave the patient 0.4mg of Nitro SL to help lower the patients blood pressure. The vital signs post Nitro were as follows BP 220/100, P 80. RR 18, SPO2 100%. The question is do you continue with the Nitro therapy since it lowered her BP or do we switch to IV Labetalol? Keep in mind that this is a high risk patient with multiple risk factors.

You are called for a 67 year old while female patient who went to her primary care providers office for dizziness, headache & hypertension. When you arrive on scene you find a pleasant 67 year old female patient seated on an exam table. The nurse tells you that the patient came in today complaining of dizziness, headache & hypertension. The patient has a PMHX: Hypertension, Mitral Valve Prolapse, Pacemaker, Reactive Airway Disease & Stroke (SAH). Her medications include HCTZ , Lisinopril 20mg QD, ASA 162mg QD, Zocor 10mg QD, Albuterol PRN. Her allergies include: Bumex, IVP Dye, Motrin & Niacin. BP 240/110, P 96, RR 20, Spo2 95% & Temp 97.8. Her Ekg revealed a Sinus Rythmn with an occassional PVC. Her treatment included O2 at 4 LPM, IV of Normal Saline, Vital Signs Q5 minutes. With a 30 minute ETA to the ED. You have the following medications available Labetalol & Nitro. What would you do & why.

There are different types of abuse & negligence. When she assumed care of this patient from the hospital staff she assumed legal responsibility for the patient's health, safety & well being. A case could be made that she had a duty to act & that she breached that duty & the standard of care by failing to monitor her patient, sleeping while the patient was under her care & then filing false medical documentation. " The act speaks for itself."

The legal definition of negligence according to Black's Law Dictionaty is as follows. " The failure to exercise the standard of care that a reasonably prudent person would have exercised in a similar position." I would have completed an incident report and documented everything and given it to my supervisor and asked to be assigned another partner.

It is totally unacceptable for her to be napping while she has a patient on board under her care. She had no way of knowing what was going on with her patient. What if her patient had stopped breathing while she was napping? A case could be made for elder abuse & neglect. It is also inappropriate for her to document in advance about her patient's condition during the transport. That could be considered fraud & neglect as well.

I don't think you did anything wrong, but there are a few things that I would have done differently. I would have wanted to immobilize your patient since he suffered a fall. I agree with the oxygen therapy and IV access. I also would have wanted to get a blood glucose level on your patient and an EKG before starting transport. I would not have given this patient Aspirin or Nitro.

I have to agree with ERDoc. I think it depends on where you practice. I started out at with a small volunteer service and worked my way up. What I will tell you is that I learned a lot more working on interfacility transports. When you work 911 you usually do more acute care including airway management and IV access, but when you work interfacility transports you usually do more in the way of cardiac monitoring, IV drips, pain management and ventilator management.

All too often we forget the basics when caring for our patients... Sometimes all that is needed is for us to address our patients concerns and use the basics such as deep breathing, immobilization, listening and positioning.

I have seen several ED & ICU patients who would have been intubated in the past for things such as pneumonia be able to avoid intubation all together thanks to high flow NC & CPAP. The ones who do end up getting intubated seem to do better with the addition of the high flow NC prior to intubation.

It is hard to really tell with the quality of the ECG, but the P waves appear to be inverted which suggests a junctional rhythm. I did notice that the P waves appear to be upright in both V1 & V2. I would like to know more about this patients history & medications.

I would avoid the use of Sux in thie patient and here is why. One of the side effects of Sux is hyperkalemia which is caused because acetylcholine receptor has been propped open allowing potassium ions to move into the extra cellular fluid. If you are concerned about your patient suffering " muscle and tissue damage" then you might want to avoid Sux. Personally I would consider going with supportive care including blind nasal intubation or BVM with a nasal airway.

I do not support giving Narcan to the general public and here is why. Narcan or Naloxone HCL is indicated in the treatment of narcotic overdoses. Narcan can have some serious side effects including vomiting with rapid administration, ventricular dysrthymias and also acute withdrawal. Narcan requires that you have the ability to manage the patients airway and that you have the ability to monitor and treat complications. " Narcan is like a band aid" It does not fix the person or their wounds. Instead of wasting money on Narcan lets instead put funds into education and mental health care.

There have been studies done in the past that show a connection between head trauma and cervical and spinal injuries. Closed head injuries can be caused by accidents, falls and related trauma.

I would have used spinal precautions with this patient and here is why. While the patient only fell 3 feet, there was trauma noted to one arm and also to his head. Since we can not see inside of his head & cervical spine then it is best to take precautions. I had a fellow Paramedic who cleared a guy who had a small branch hit him on the head while trimming trees in his yard. The guy looked fine except for a small laceration on top of his head. The Paramedic opted not to take spinal precautions, but when they arrived at the ED a CT was ordered and it revealed a sublaxation of his cervical vertebrae.

In the back of my mind I was asking should we give this lady 5mg of Metoprolol IV to slow her rate & I was wondering why she wasn't on coumadin or some other agent. The other thing that I thought was odd was that she was not given Heparin or Lovenox.

If you look at the study, you can clearly see that there was some benefit to giving Metoprolol. Does that mean we should give Metoprolol to everyone, probably not, but I think the point that the authors were trying to make is that if we can reduce the size of an AMI and decrease heart muscle damage then we can reduce the associated problems that follow like CHF which can not only be costly but very debilitating.

They opted not to give her anything for rate control since she was already on a beta blocker. Instead they opted to treat her upper respiratory infection & also her low magnesium level. I checked on her the next morning. Her A-Fib had resolved. They increased her beta blocker, added magnesium oxide.

The METOCARD-CNIC Trial in Spain recently showed that giving the low cost medication Metoprolol in the field for patients experiencing a heart attack may prove to be beneficial. How many of you carry & administer IV Metoprolol to patients experiencing heart attacks in the field?

Giving a medication the wrong route.... IV Vistaril?

Well as a new provider I would encourage you to partner up with a seasoned provider & remember these rules. #1 Remember your ABC's. #2 Remember when all else fails to use your BLS skills ( BVM, Control Bleeding, Nasal Airways, Oral Airways, Oxygen & Suction etc) #3 Never assume that your oxygen is on & that your IV is patent. #4 Recheck & verify.

Upon arrival at the ED it was discovered that she did indeed have an upper respiratory infection. Her labs and x-rays revealed and infection in addition to a magesium level of 1.3. She was given 2gm Magnesium IV, 1 Duo Neb Treatment, Solumderol 125mg IV & 1GM Rocephin IV. She was admitted for 23 hour observation.

During the first five minutes of transport she reports right sided jaw pain x 2 days. Her temp is 37.1

You are called for a 65 year old female patient complaining of increased shortness of breath. Upon arrival you find her sitting on her couch. She is on oxygen at 3 LPM. She tells you that she has been experiencing increased shortness of breath times 24 hours. She states that it started after going outside in the cold. She is conscious, alert & oriented, her skin is pale, warm & dry & her & pupils is equal & reactive. Upon further exam you note no JVD, trachea is midline. Patients lung sounds reveal wheezes. Her abdomen is soft, non tender & slightly distended. Patient has good cms. Patients vital signs are as follows BP 136/66, Pulse 137, Respiratory Rate 22. Patients Finger Stick is 118, Pulse Oximetry is 96% & her EKG reveals an Atrial Fib at a rate 137 with pacer spikes noted. She tells you that she has a history of Intermittent Atrial Fib, Hypertension, High Cholesterol, Tachy-Brady Syndrome, Pulmonary Hypertension, Mild Leaky Heart Valves x4, Asthma, Dual Chamber Pacemaker, GERD & Anxiety. Her medications include Albuterol MDI PRN, Dulera MDI, Lasix 40mg BID, Aspirin 162mg BID, Zantac 150mg BID, Zoloft 75mg QD, Zocor 10mg QD, SL Nitro 0.4mg PRN & Metoprolol 100mg BID. You have a 30 minute ETA to the ER. So what do you do?

It sounds like your patient was developing Rhabdo. More than likely from his injuries and thrashing around on the board.

It sure sounds like motion sickness to me. Probably caused by the movement & positioning of the patient. I always liked to premedicate my patients with either IM or IV Benadryl or Phenergan. That way there is no messes to clean up!