JackMaga

Reading the original post I thought the woman was actively convulsing... I agree with CBEMT, it could very well be a distonic reaction, however the drugs she's taking don't cause such reactions... On the basis of the assesment and futher infos my workin diagnosis is hyperventilation crisis due to a stressfull situation; I would monitor her, try to reassure her and transport to ED. I would stay away from pharmacological sedation, particularly with benzos (who the hell prescribed her Oxazepam anyway?! ) and only try to calm her down talking to her. I'm at loss here...

Ok, let's start: get the husband and relatives out of the room; explain them you will get to them at soon as possible to ask them informations about the patient and to inform them of the situation; get the pt. on the floor in a position from where we can work as confortably as possible particularly at her head since we're probably going to be working on her airways; start primary evaluation: is she moving enough air? how's her pulse? Do we have vitals and what's does her rythm looks like on the monitor? Start O2, get a vein. As soon as possible I would like to talk to the husband: he said that the back pain had been going for two weeks: did they see their physician? Any history of hypertension, renal disease? Did they do blood/urine exams for the back pain? How about the previous pregancies, was there any problem? My first bet would be eclampsia but it could be a lot of other things...

I think chbare point is a very important one, which also respond to tniuqs poignant observation... from the looks of it it really seems like necrotizing fascitis, however one can never be too sure; getting cultures drawn before starting abx will ensure that, if in the following days things doesn't go as planned and the ICU physicians need to reasses their initialy diagnosis, they at least have coltures results that can help them. So yes, the cultures won't change anything of the initial abx therapy this patients will get in the emergency setting (EMS/ER) and in the first days of his loooong ICU stay, however it may make a difference later, if the diagnosis needs to be reevaluated... Yes, this patients really looks like he's rolling downhill... however there's no evidence that starting abx 20 minutes earlier does change patient mortality. The focus is on starting abx in the first hours, and surely before ICU admission, however it doesn't appear to be such a time-sensitive treatment so that minutes count. What really need to be start asap is aggressive iv fluid administration, as that is one of the early interventions that really has been shown to be a life saver; this patients is only mildy hypotensive, but gives his story of hypertension in multiple treatment, I'll take a gamble and say tha his usual BP is way higher than 110/30 (besides that's quite a big differential BP!)... All in all quite a challeging patient...

Great... now you have screwed my chances to take a couple of hemocultures in the ER... Seriously though... do you think this patients warrants aggressive antimicrobial therapy in the field or can he wait untill you get him in the ER and cultures are drawn? Does the transport time to the hospital play a role in deciding this? How so?

I'm sorry to hear it's so difficult to retain your physicians... I'm curious as to the why of it: not enough pay? Career opportunities? I'd like to see Canada, but to work there? No thanks...I don't mind the cold but one of the reasons I chose Emergency Medicine is to work EMS... you won't drag me out of my ambulance alive! I don't know much of the spanish system, but in Italy non critical calls are usually trasported by an ambulance staffed by an EMT/RN; in some systems that use a tiered response sistem (EMT staffed ambulance with MD/RN rapid response vehicle) non critical patients may be transported by a BLS crew of 2 EMTs.

I say this is old news... it always amazes me how some people take these dogma so literarly! The golden hour concept was a great idea to make hospital administrations understand why having to call the surgeon from home wasn't good enough for a critical trauma patients: if you were going to need a surgeon at all, you needed it to be ready within few minutes, not a couple of hours or so! That said, I think the golden hour was and still is a great visual idea: everyone can imagine this big clock ticking away as minutes passes and the patient dies away, even your hospital budget manager! Does this mean that saving 2 minutes will make a significant statistical difference in mortality? Of course not! I don't think even Dr. Cowley meant it...

Well that is a point worth considering... as I said, the cost effectivness of such a solution is highly dependent on the type of healthcare and welfare system that a country has... it will come easier to those that already have some sort of public funded healthcare.

I think it depends on what do you consider sick/not sick to be... if sick/not sick means unstable/stable as in recognizing a near arrest patient in respiratory distress thatt needs immediate ALS care, or any other immediately life treating condition then yes, I think a BLS provider can and should be thaugh what to look for; however usually it takes only a visual primary survey to recognize such critically unstable patients so that the assesment a basic need to do is really well... basic! For example there's no need to palpate an abdomen or auscultate lung sounds to make a decision between critical and not critical. If, on the other side, by sick/not sick you mean be able to recognize, based on your physical evaluation and history, that a patient, while stable, is suffering from a condition that might make him deteriorate within a short time (for example recognizing the presentation of a possible polmunary embolism in an otherwise healthy young patient with dyspnea and chest pain) then no, I think most basics will not have a clue... they might tell you what they're seeing if you ask them, but usually don't appreciate the significance of the signs they arere reporting, nor their relative importance.

Well of course a Family Practice physicians would have no education in prehospital care, why should he? He is not going to provide EMS care! Perhaps I wasn't clear but we are not talking about a system where any doc can hop on an ambulance just because he has a MD behind his name! And yes, I think that a physician who has completed a 5 years residency in Emergency Medicine (which includes EMS care) is more educated than a paramedic with a 3 years degree. Whether this means that the outcomes wil be better or it will be cost-effective is subject to debate of course, and the benefits may be different from one healthcare system to another. I can think of many istances where US paramedics care was reported as way less than optimal...

Kant said that "eyes will see what the mind already knows"... healthcare providers with only basic trainig (such as EMT-Bs) may actually do the same assessment of more educated providers, however they do not have the knowledge necessary to appropriately interpret what they see, so most of the results of their assessment would go. Even more, patient assessment is part of the providers differential diagnosis reasoning: basics don't have the fundamentals to do a proper diagnostic reasonig since they lack all A&P, patology and so on, so even when they're assessing a patient I don't think they really know what they're looking for...

My fault... it was intended as a funny remark, no offense intended! I'm sorry if you felt it was disrespectfull! I don't doubt that many paramedics have the knowledge and education necessary to fully and completely evaluate and treat their critical patients: my post wasn't intended as a paramedic bash... We're talking about education, and specifically about whether such thing as BLS and ALS care exists: most of the posters here expressed the view that patient intervention should be seen as a continuum, non categorized as advanced or basic. I completely agree. However it makes my self think: if field iterventions are considered as a continuum, why field care in itself is considered to be separate from hospital care so much that a dedicated provider has to exists? Why those that traditionally provide general medical care to the community (that is physicians and nurses) don't do it in the field too? Why do you feel this is appropriate? Please consider this as an honest question, as in my part of the world all medical interventions are performed by nurses and MD, wheter it is in a operation room, a GP office or in the back of an ambulance or an helo... And tniuqs, I never implied that you don't need the tools... I just said that the discussion was about education, not about skills... I agree sometimes there may not be any difference, sometimes however it might... in my system for example I can refer my patient to their GP, I can treat them on scene. I'm not restricted to any protocol, I can have my own drug choice to carry on the ambulance; when I bring a patient to the ER I can continue my care until I have done all diagnostic and stabilization required and he is ready to be admitted to the hospital, so that he actually had one single physician who took care of him from the field up untill he is admitted to the ward... As the implication that a physician would lenghten the time on scene, being an emergency physician means also that you have to know when you can stay and play and when you have to get going... after all I'm not some internal medicine doc who won't start treatment untilhe has done recording the pt. full family history!

I don't have the capability to do a catheterization in the ER too, so maybe these patients should be treated by paramedics in the ER too untill they get to the cardiologist? It's not about the skills one can perform or the drugs one can administer: here we're talking about the knowledge and level of education one should have when treating a patient in the field...

What about you simply disband the idea of a separate profesional who provides medical care outside the hospital and make properly educated physicians and nurses run EMS? It always puzzled me why, in certain sistems/countries, if someone had an AMI or any acute medical condition outside hospital walls he would be evaluated and treated by a technician while if he came walking to an ER he would be get seen by a nurse and physician...

Hey all! I already posted sometimes ago when I was still in medical school but then got back into lurking... now I have some (little) extra time so here I am again I'm an Emergency Medicine resident and former EMT from Padova, near Venice in Italy; and I look forward to some fine discussions! Note to Dust: please go easy on me man...

That's not the only one... in Italy we do it the same way, and I'm quite sure several other EU conuntries also staff MD and nurses on ambulances (maybe the Netherlands? Belgium?). As for the remark about quality of EMS physicians otuside France... I should take offence! To the OP: I agree with akflightmedic, you will have a hard time getting any of your training recognized in France...

Italy rulez 8) Very good scenario chbare! Very refreshing since it involves both pre and in hospital elements, I really like that! I wonder how do you create them! You must have both a fervid imagination and the whole Harrison's stocked in your mind!

Eosinophilia leads me to two possible aetiologies: either an allergic one or a parassitosis... given the recent history of outdoor activities and no known allergies I would lean toward a parasite infection. Toxocara canis I think would be a suitable candidate for this presentation (eosinophilia, pulmonary simptoms, abdominal pain, hepatomegalia, not to mention having dogs all around the place); a stool analisis should confirm this hypotesis...

8)

Ok so how about we talk a bit about his holiday? I'm particularly interested to know if he did scuba diving, or something like that... Also if he had any other phisical problem during the holiday, even mundane things, like a one-day fever, general malaise, he got stung by a fish... Also, what ethnicity is he? BTW as I'm inquiring about his private life, I hope my partners are giving him O2 (i'd stick to a nasal cannula right know), establishing an IV (TKO rate) and performing a 12 lead ECG.

I think he refers to the pain medication drug Tramadol, sold as Tramal or also as Contramal. Tramadol in a sintetic partial agonist of opioid receptors; it also inhibits serotonin and noradrenalin reuptake; so its pain decreasing effect is actually due to two separate mechanisms. The problem of administering both tramadol and morphine (or fentanyl or any other full opioid receptor agonist) is that morphine will find part of the receptors already binded with tramadol: since tramadol is less powerfull than morphine your overall pain controll effect will actually be less! So it really doesn't make sense to give both of them!

Where is he coming from? ANd about those diminished lung sounds: are they diminished bilaterally? Do I hear anything other the normal MV (like crackles, wheezes)? What about heart sounds? Is there JVD?

Once a 20yo girl came to the ER because she wanted us to check if she was virgin or not! :roll:

Well, I don't know, but, don't you think you are a bit too harsh with yours FF? After all, they're trying to help you doing something that's not included in their job! Here in Italy, the FD nevere ever comes to a call, unless there's either a fire or the need for technical rescue, so I think it would be great to have a couple FFs at my side during the more tough calls, even if it does mean tell them what to do step by step.. Again, it is not the kind of thing they're trained for...

And I thought bad use of the ER was a typical Italians problem! Last week a girl came to the ER because she couldn't get her new contact lenses off :shock: It seems that stupidity joins all people!