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It is going to be whatever gets my Co2 near 40. I want to keep my volumes at the lower end to keep chest movement minimal. PEEP will be set at 5cm to replace physiological PEEP made at the vocal cords, and taken away by the tube, + 5cm extra (10cm total) for "internal splint". This PEEP aint no game, I need to be really careful of hypotension, and REALLY aware of the pneumo possibility (more like inevitebility). Ok, two quick questions about stabilization. Can a flail segment safely and effectively be stabilized using a KED? My partner said it could, but just wanted to get other input. Also, I was told in class not to use sandbags, IV bags or anything heavy due to the fact it will cause respiratory difficulty or make it worse. Are sandbags still an accepted practice, or is it best to use bulky dressings?

NOW where is chbare when you need a good debate ... sans quantum physics that is ! :devilish:

ah some feed back SWEET that said I do not know everything myself (was that my outside voice ? again) Back to BLS crowd with Mobeys rolled up towel or pillow suggestion ... could one use Tape to hold it in place ? No CPAP comments ? cheers

Seeing as no one has posted and picked up the obvious observational error I made, ps no bilateral chest tubes but appears he does have a radial art line in situe but why was the attendant taking a radial pulse then ? OK a simple O2 mask? No pulse ox probe (obvious anyway) No collar ? What is that beeping in the back ground ? Any other possible vascular injuries like possibility ie location, location, location ? No one has tried to estimate the extent of the ribs segments involved ... and I gave a hint where to start. How about a Cardiac Contusion ... any way you get a working indication or handle on that with the toys standard in the back of all trucks ? BTW this has got to be very very old vid, no ECG monitoring ? HUH is this third world ER ? In most cases in any modern ER, would there not be a dozen stickies on the patient already maybe a 12 lead or am I missing something ? ALS or CCP guys ? Would anyone RSI this patient ? Any guesses on what and how this patient should be ventilated ? Ventilation ? Mode? Maybe AC or CMV ? Volumes in AC / CMV ? Trigger Sensitivity set ? or Pressure Control (so what PIP peak inspiratory pressures) ? What respiration rate set initially ? or PS = Pressure Support he does have respiratory drive ..... FiO2 ? PEEP perhaps ? Splint with pressure from within ? Still no answer from the BLS side of folks here ??? Would ANYONE assist with BVM ? AND with a new toy they soon will have on most gut wagons, CPAP anyone ? Ok say one uses CPAP, just how would one "titrate to effect" the CPAP levels in the field ? hey I am willing to play or debate "many options" ... but if there is no willing to try. My point back to original post re DANA OAKS ... in EMS its all black and white protocol driven monkeys (the gauntlet thrown btw) In Medicine everything is shades of gray.

Mateo et all: I have been standing back watching this thread not commenting ... yes mobey / rock shoes ..VERY atypical and unexpected. I have returned very recently from a Respiratory Conference and the "topic" of education for EMTs and Paramedics was discussed is some retail with a respiratory educator a Dana Oaks btw with similar status in the EMS world as the great educator Dr. B. Bledsoe. Dana Oaks (due to my background and some opinions felt that I too should get into education, possibly write a book for the EMS types as this is my first passion, although as rock shoes will be chuckling my editorial writing skills are less than a professional level So the Flail Chest and "some" of the prior comments: I will make an attempt to provide some improved understanding as I have had to deal with a "few" these and without doubt some of the most difficult patients to manage. Firstly bit of clarification we breath "in spontaneously inspiration" by generating a negative interthorasic pressure with the diaphragm (contracting) and the main mucles of respiration in the adult, in symphony the ribs and intercostal muscle (contracting)up and out this is called the "pump handle effect" hence physics all things attempting to equalise (as now ambient pressure) is higher The Air Goes in, in EMS speak. Note in this patient there is FORCED and accessory muscle usage further increasing WOB Work of Breathing. Exhalation is passive in spontaneous breathing and even when ventilated as mobey refers, no offence these are NOT balloons ... pop a hole in a balloon and the party is over ... the good lord put a few safeguards in place for survival a thing called hysteresis, the lung by nature will not go flat like a tire. A comprehensive link here ... to put the YAWN of pulmonary mechanics into a better light and the complexity .. look at Lung elasticity Chest wall elasticity and FRC ... functional residual capacity. http://www.anaesthetist.com/icu/organs/lung/Findex.htm#lungfx.htm 5 to 6 ribs fractured in non communicating segments is "typically" the accepted definition of Flail Chest and also test question in Canadian National Final Respiratory exam's, no easy exam btw. That said 2 to 4 are still Flail but the integrity of the "pump handle effect" is no where near pronounced with morbidity mortality far lower. Now just fer fun go back and look at this excellent "old" video and estimate the number of ribs possibly affected count down from angle of Louis thats rib 2 isnt it ? BUT this dude is in deep ca ca, he will eventually (due to extreme WOB) crap out, deterioration blood gasses then go outa whack and stop breathing. HE will be Intubated ! The MOI is massive blunt force trauma is this pulmonary pathophyiology and traumatic forces is HUGE .. my guess is unbelted in MVA / MVC and steering wheel contact high speed solid object. Look a tad deeper ... yes as stated a pneumo = air between the "Lung" and the "Chest wall" with a "Tension" many being that the air/ pressure in the wrong cavity will increase to the point of "crimping the aorta" The bandaging in the vid is most likely hiding the chest tube as with large Flail it will be assumed that "buddy does have a tension or soon will" because of the fractured ribs but then look a bit deeper as the MOI also affected "other" tissues underlying for example the Heart ! Traumatic Asphyxia is also in this toping the hit parade with this polytrauma patient. Now remember that under every rib is a vascular supply, so hemo thorax is highly likely as well ... also note one can blled out with a costal artery tear in of itself ... oh yeah baby as is pulmonary contusion hugely complicating a high possibility of ARDS and If I were a betting man "post op" this patient is Tracheostomy and long term Ventilation ... add in VAP Ventilator Acquired Pneumonias. A personal anecdote: Had an old farmer, he got run over with his own tractor (posterior Flail) lacerated a costal artery on asa (we didnt know this) and put enough pressure in retro peritoneal space to obstruct blood flow to Kidney . Yup my buddy Metro (a good tough man) died from this complication of renal failure and sorry bit of PSTD flashback there. One day he told me "hey don't worry Squinty" I have a first aid kit in my tractor and I could use it I "meaning me needed it" what a fighter he was. This was after weaning him off the ventilator and Trache plugging trials, its a very different look at the patients we deal with in EMS maybe a few hours contact then off we go ... as a bedside RRT and initially acute then the chronic long term care of people ... you develop a real relationship over the weeks / days / months. Funny thing how some people you will never forget RIP Metro . More things to consider a bronchopulmonary leak/hole (major airway leaking air directly into chest cavity OMG these are so difficult to deal with in ICU sometimes requiring a Carlins Tube and bilateral Ventilation ... ie one lung ventilated independently of the other lung ... umm my brain is going to explode now. But note well was anyone running around in that vid ? NO and why because buddy was waiting for a Thoracic Surgeon consult my bet and he already had bilateral chest tubes in situe because he IS going to OR and STAT like, some Chest Crackers will suture the broken ribs with wire ... some do not ... using PRESURE PRESSURE PRESSURE ... I like that btw Mateo. I will leave that to next post, because presently there ARE some under used therapy's even BLS that could help to GET this patient to hospital .. but can't steal all the thunder from Mateo as I think I know where he is going .... ps good post btw So once we Intubate as mobey refers ... we flip the entire physics of normal and negative pressure during inspiration pressures to positive NOW this ALSO affects the heart as the Right Ventricular Pressures increase, right ventricular filling pressures go up (in normal spontaneous ventilation LA filling pressures are "helpful" that said this ALL is increasing work of the heart, With the Lungs falling between the left and right side of the heart, this ultimately affects volume and refilling time to the Left Ventricular hence overall output is reduced and as is left atrial pressures (decreased) so no atrial kick .... Starlings law is affected. All that said this is just with simple Intubation gets even more complex with Intubating the Flail Chest Patient, massive fluid infusion will not solve this problem its mechanical in nature but moderate volumes can help, even in virtual all Intubation(s)that said hypoxemia due to other injuries always a consideration but if hgb is steady state this can assist in diagnosis of other bleeding issues. In the field in EMS we are still in the dark ages teaching putting a heavy bag IV or other to splint .. this is Korean War technology for BLS guys and girls "injured side down may can help" then again how can one do affective "C" spinal restriction ? OK agreed .. pillow well most of these injuries are decreased LOC so can try, and O2 absolutely ! Load and Go now that said ... careful you get to destination. ALS decompress with big bore and bilateral, a must in my books, the patient will not even notice the pin prick, the big deal here is many Ditch Doctors cannot recognise that the caths have plugged out so keep checking the Cath for air movement. Ashermam chest valves (if you have those on car or a 3 sided seal with an open pneumo can frankly plug out quickly and then that open pneumo thorax becomes closed and results in a tension pneumothorax again life threatning, point I am making is dillegence and lots of revaluation en route. A rapid hypotensive event PEA and or and brady arrest are some diagnostic signs ... dark humour there! I will not comment on air transport but many times mobey, rock shoes and myself have to consider this is again a very serious complication with that damn Boyle's Law ! cheers for now.

My arm is getting longer (btw) agreed their are over 190 industrial operators out in AB land many Ma and Pa shows that underbid the established operators ... but the real problem is that our regulatory body does not have any "investigators" one has to make a written formal complaint then they are more interested with protecting the "public" as opposed to regulating Industrial EMS BUT OH + S does have VERY sharp teeth ... I have observed unregistered individuals practicing. Charging out for an ACP with less than a EMR kit in the gut wagon .... this is OH+S regulations fault in my opinion as they have not updated for 25 years ... hey an RN or Paramedic needs a bit more than a Level 3 FA kit ! sheesh. Field Ambulances with no stretchers ??? AED with no screen on a job in a 3rd world country with 3 anti arrhythmic drugs .... LOL joke was "short code" Meds so old that they are congealed in the vials, but are ordered and will be there soon .... pfft ! Monitors that do not work or have not been biomedical tested in years (its a yearly deal btw) Lack of Medical Directors (or just they used to be and died and we are looking for a new one) +++++ And tires on the MTC .... thats the big one for me a DGA = dead give away. Presently their is a moratorium on EMR applications for schools ... so buyer be ware, I have no comment on the institution noted above. And if someone is not getting paid ... Employment Standards AB is NOT the way to go ... a Labour Lawyer is (learned my lesson the hard way) cheers and welcome to the world of industrial EMS

Can I get your autograph now ... in invisible ink ? But you know you now WILL be forced to change your avatar picture so I located one for yall.

Annie: I have to know ... is their any updates with the ACP or EMT/PCP working to full scope of practice in the ER ? Has HSAA or anyone filed a grievance about the RN coping an attitude in this turf war vs what is best for the patients needs ?

From CUPE website

With Permission from editor Michel McKay editor Paramedic Network News: I am informed that PAC representatives will be in attendance as will the Alberta College Of Paramedics I suspect Dave McLean the leader of Guard of Honor EDM to show respects and solidarity of EMS across Canada for the lost of our Brother and Sister in this LODD. in solidarity late edit ... if any member would wish to donate a couple of bucks for a memorial again PM and any member from across Canada ... I can pick up in Vancouver Airport and transport, flights into Victoria will not work well, one need's to ferry from Tsawwassen (Vancover) then express to Nanaimo is the only way to go.

http://www.emtcity.com/index.php/topic/19016-ambulance-goes-off-cliff/page__pid__248383__st__10#entry248383

I have been informed that a representative of Paramedics Association of Canada (Benevolent Society) will be in attendance for the services (when announced) If anyone in Western Canada would care to show support and like to attend ... contact PM. rock_shoes: Do you have a email contact so that members of this EMT community can forward their professional condolences to the families and colleague's ? cheers.

I recently returned from a fishing trip in that area, this road is a bitch in dry weather and during the day. I had stopped by in Tofino and Ucluelet to shoot the breeze with the crews ... the door was open ... the coffee was on ... got nothing more to say than #$@! this so sucks.

Mother ? well maybe ... but my physiology is more akin to MOFO ... LOL.

Firstly: 1- Were these "patients / prisoner's " actively having CVA during a flight ? 2- Were the events due to the flight or did they have a history of CVA, TIA or uncontrolled HTN ? 3- Was the aircraft pressurized ? Ok late edit you said @ 40000 .. what type aircraft are they using ... a Lear ? thats kinda high for most aircraft used .. The movie Con Air, (unpressurized tramp WW2 transport) but got to love Cage, Malkovich, +++ Star filled "fiction action movie" but the best was Steve Buscemi ... he played a great evil sicko. A couple of links for physiology in relation to Boyle's Law, (the most likely the culprit) Hypoxia at altitude and the ODC shift at altitude. With the increase incidents of DVT leading to CVA / PE with stagnation of venous blood flow while sitting for long periods ... hope that helps, well a bit. http://www.cfpc.ca/cfp/2004/jan/vol50-jan-cme-3.asp http://books.google.ca/books?id=kLW-kIphsnwC&pg=PA47&lpg=PA47&dq=flight+physiology+in+stroke&source=bl&ots=8foHjipf03&sig=XO5obEuwFnIoGN0qhSiiinf5Sdo&hl=en&ei=D6W0TIm1OsqbnAeBwNX-BA&sa=X&oi=book_result&ct=result&resnum=6&ved=0CDMQ6AEwBQ#v=onepage&q=flight%20physiology%20in%20stroke&f=false In passing and just anecdotal, this also has been my experience as well, for some curious reason with critical patients decide to "crash" when are on descent from altitude, although seizures in my experience are more much more "popular" on take off, (G forces and Noxious Stimuli) I highly suspect. cheers

I have to agree, the insanity of the "regulations" for travel by air are just that. The Israelis have it figured out they do staged "observations" of possible suspects background checks +++ Two other observations: 1- Was awaiting in line to go through security when a women in her 80s was mentally accosted by "security experts" that did NOT have a good grip of the English language (yup another topic) She was stopped because she had more than 100 mls of "denture cleaning paste" now very embarrassed and quite pissed off, so she squeezed out half the tube into one of those gray change trays asking if that was less than 100 mls now ? This much to the amusement of an RCMP officer and myself standing watching the idiotic actions of the security experts .. we both stood their laughing and the look on the faces of the crowd, who were also very amused / annoyed at the delay, but now clapping. 2- My best friend who has a "concealed carry permit" well he is a Captain with a Major Airline and was the Kanadian equivalent an Air Marshall in a past life,(shush) he got busted by "security experts" and not because he had a handgun in his bag with appropriate documentation, but busted and had his nail clippers were in his overnight bag, then removed while he just shook his head in utter disbelief. He WAS the f*******g Captain .. like with 4 bars on his uniform too. Just what was he going to do hijack his OWN aircraft ? Besides the fact that this friend also has a "crash axe" clipped behind the left seat. I wish any terrorist a hearty "good luck" if they walk uninvited into his cabin .... ! Yup the regulations of air transport are beyond rational thought process these days, water bottles, toothpaste, or a jar of peanut butter +++ at the Edmonton International they have a glass viewing cabinet of all things restricted .. the situational irony is that NONE of these confiscated / displayed items are dangerous in any way shape or form, proof positive to my way of thinking that harassment of passengers does exist based on rules that are simply idiotic. Personally I believe they should do "racial" profiling, just look to the last fool trying to blow up his underwear going into Detroit with possible "undetectable" binary explosives. HE was from a known terrorist country. He affiliated with an extremist Muslim group. He had ONE way ticket, purchased by ANOTHER party, purchased within ONE day prior to flight departure. He and had NO farking PASSPORT on an INTERNATIONAL FLIGHT out of Heathrow ... WTF? So good job "travel security experts" I sure feel safe having handicapped folks getting their wheel chairs searched, busting granny, and the Pilots getting strip searched ... <insert sheesh> cheers

Update AB Protocols / Guidelines: Acting Senior Manager, Emergency Health Services has contacted myself, a very professional note and very polite, the release of new EBM protocols to the public (pubic domain website) and implementation of new EBM Protocols is Dec 1st 2010. Apparently they (AHS) are working some of the "bugs" out like wording and drug dosages as some newer studies will impact. One of my biggest questions with purely EBM protocols is just what studies and meta studies were evaluated ? Point being that "some" studies as in OPALS are misinformation and were dated before they were released. I can only hope that level headed and peer reviewed are applicable to our very unique Alberta environment. Another concern is (with the AHS takeover) are we looking to implement 'best practice' or "most cost effective practice" as some of you are aware their just may be a bit of a "crunch" when it comes to budgetary concerns, that said this is government and I would hope that unbiased Medical Directors we appointed to this Health Policy and Service Standards Board. Question is: Could we be basing practice on studies that were not derived or applicable even in Alberta, as many of the studies (i.e> wong et all) are out of the USA. Limiting practice / protocol without follow-up peer reviewed studies to validate, could be an error in of itself. I have observed in my experience with medicine that things do swing from one end of the spectrum to the other is very short order. Lastly but not "Leastly" (sp) Look at the implementation of NIPPV ie in EMS refereed to as CPAP (quite obviously from the choice (minimums) and many sub contracted services WILL purchase based on lowest common denominator ie the device the Boussignac mask is folly and to best of my knowledge no "experts" from other regulated health care professionals were consulted like RRT's. Point in fact: a most current and excellent example during the H1N1 pandemic the Federal Government and without consultation from experts purchased en mass the Neuport 50 ventilator and this ventilator did not HAVE the capability to actually ventilate an ARD's type patient, nor were proper in-service provided to the VERY group that would be pressed into service to use them ... Most shamefully we (Canada Health) ignored or somehow forget to consult the other experts in their respective fields of specialty. So my question remains just who was on the development team (it may be a premature contrarian position) but I believe we just could see some "personal bias" or protocols based somewhat on budget restraints, but I hope not. Side bar: spend ANY time with the Master Contrarian DR. Bryan Bledsoe and one looks at both sides of the coin ... and the edges too ... When it comes success or failure with the NIPPV / CPAP devices, I have always been of the opinion that the success of this or that device is VERY dependent on the clinician applying that device, my point being that this is very difficult to be "quantified" by any study. More to follow on this topic .... I must to go to the Airport and pick up a life time friend that I have not seen in 3 years and that drinks rhum. cheers

Well look what the cat dragged in ... Rid where have you been ? stuck in the time warp called Oklahoma ? Welcome Back.

Yeah think ? Once again (but on a different continent) the hose monkeys use the same methodology of a claim to faster response tine TO SCENE ... and after that the FF clock stops, yet for EMS the clock just got started. Not to forget that during a global ressession that somehow a complete restructuring of services will not cost MORE to accomplish this foolish goal, instead of funding the EMS services to attain the "golden response time" Does it get more daft ? Fund the service to the level required instead of throwing out the baby with the bathwater when one needs just change the nappy. Has everyone in government just dropped IQ about 20 points ? Maybe address this issue FIRST ? http://www.heraldsun.com.au/news/victoria/victorian-ambulances-called-to-tight-pants-pimples-and-toothaches/story-e6frf7kx-1225932916657 cheers

On would think as a registered Provider in Alberta that the protocols should really be posted for Public access, like the ACoP website as a link ? 1- There are many in AB that work primarily in Industrial EMS and need continuity to "hand over care" to a local AHS provider, this to maintain medical coverage on a work-site and prevent work a stoppage in a multi million dollar operation, in regard for OH + S regulations. 2- These new protocols / guidelines / standing orders have been developed with taxpayers moneys and should be made available to all, like the MDs and RNs working in rural areas) i.e. for continuity of care. cheers

Agreed that AHS is stepping into very complicated areas of labour and medical legal issues under the guise of "improved utilization" again without doing their homework or putting into place good legislation before implementing a "dry run" to find out the problems of blanket changes ... just look to "dispatch problems" an Gene Z putting a "stop order" on that little issue. I support the ACP in ER as this will be the future. That said: clearly deined roles and job description HAVE TO BE ON PAPER BEFORE ANY IMPLEMENTATION. Some questions should to be asked: 1- So EMS can take a CNA / LPN job but not an ER RNs job, I guess one CAN have your cake and eat it too ? Curious ??? 2- Is EMS is trained to provide long term care .. short answer NOPE. The priorities HAVE to be established first don't you think ? Besides that EMT/ Paramedic can not be in 2 places at one time, a 60 second to respond ... what if you are providing assistance in for a "bath" and get a call out ... leave the patient ? Hey were good but not THAT good. Do you have clearly defined "job description" in this long term care facility as an EMT, or are you just the Head RNs bitch ? Medical Legal So just who is covering with the medical legal issues as in i.e. say if one drops a patient in Hospital? Has AB Health placed a a blanket insurance policy or have they even been asked ? Put request on paper for clarification it is your legal right to be informed. The "past" medical legal under HDA the "local medical authority" ie the Medical Director were the undersigners ... following that and the transition to "the perfectly blended system" just who is signing off on local protocols and responsibilities lately ? Can you as an EMT deliver oral meds or assist in IV therapy as that is within scope of practice for REMT or is one restricted just to lifting ? (NB. Back injuries are the biggest risk assessment for Workers Comp for EMS across the country and now the government is asking for more "lifting" ONLY ... hmmm interesting. 3- Agreed one MUST contact a local MLA concerning these new and improved Conservative Health Care incentives, there is an election comming soon AND the Conservative Party is attempting to keep the public happy and keep issues EXACTLY like this very quiet and out of the news, perhaps the local media should be contacted ? ie NOT RUETERS Local health care workers placed at odds over new incentive by Alberta Health. 4- Has HSAA been contacted ? So just where do they stand in all this, this is a change of job description and responsibilities. 5- "the ER is OUR domain, not yours" OMG it is ? Firstly the ACP/ EMT-P working there "get a set" RN can not restrict scope of practice under the current legislation and the HOSPITAL is Public Property, so stand your ground based on what is the best practice model for the community ! If any one single RN has stated this in public they are in deep ca ca. It sounds as if the whole concept is to use ACP to use their skills in the ER due lack of rural MDs. This is already an EPIC FAIL based on RNs territorialism AND NOT WHAT IS BEST FOR THE PATIENTS ! 6- "Nursing staff made it very clear that they did not want EMS in the hospital" Ok since when does Nursing dictate what specialty services provides what services, perhaps contact the RNs regulatory body CARNA maybe a complaint is in order as well or grievance against any ONE individual that has voiced opposition to the improved delivery of care. http://www.nurses.ab.ca/Carna/index.aspx Look to code of conduct. http://www.nurses.ab.ca/Carna/index.aspx?WebStructureID=1212 RNs do not stand a hope in hell of any public support if this hits the media and IMHO thats where this should be headed if the goal is to be accomplished. btw (If anyone is afraid of job security ... I just may know an individual that is NOT employed by AHS and has been very OUTSPOKEN in these areas) Or perhaps Contact Wild Rose Party about any concerns, as I believe they will be most pleased to open a dialog they have with that individual. http://www.wildrosealliance.ca/ cheers Late Entry ... just guess who my Wild Rose Constituency President: Tim Essington REMT-P about time we got involved in our future.

Any mention of CPAP or NIPPV or standardize Transport Ventilators capable of NIPPV Please don't tell me that AHS cheaped out and chose the Boussignac CPAP device. And is TPA going to be on ALL ALS cars ? cheers

Sorry but no protocols for this in ICU or oncology besides not that many standing orders or protocols for RRTs in the ICU/ Floors as primaraly we work from the MDs written orders or verbal, then the RRT enters those in the orders, we are permitted to do this, MS as per neb would be stretching those limits big time. That said" Orders can vary dependent on the most recent study that they, the Inensivist has just read and / or individual fellow / resident writing those orders. I have not nebulized M/S in EMS field. cheers

OOPS I stand corrected, FF couldn't get a BP ... so with decrease in B/P was there compensation in Heart Rate i.e tachycardia or did a pulse rate of 70 remain a constant en route. btw trendelenburg has lost favour as the studies suggest it is useless. Well that kinda changes the picture a tad ... hmmm. . Thanks. Could you explain that theory ? So what was the MD working dx ?

Ok some "thoughts" here but more questions right now, I have to ask about the initial BP of ~70 (FF EMT ?) most likely a decrease in distal perfusion (pallor, cold and diaphoretic) results in erogenous Pulse Ox readings but then you state sats reading 97% on R.A. Curious that a patient presenting "shock" that the Pulse Ox would read accurately. Maybe that is telling you something about accuracy, maybe "pilot error" ? Like what meds ? Thyroxine ? and just what anti-hypertensives (beta blockers or ace inhibitors ?) rather important don't yall think ? and is the patient compliant with Rx ? You seemed to be very "focused" on BP, just where is the Heart Rate (s) and Respiratory Rate (only one time mentioned) Any odd respiratory patterns (like cheyne stokes) besides NSR does't answer my queries. These Vital Signs can be VERY helpful in any senario presentation just saying not getting the whole picture without these little "thangs". MOST in EMS use GCS i.e. the Glasgow Coma Scale to describe LOC as that would be a superior idea in any scenario presentation it certainly beats (underline in red) lucky for you, that Dustdevil is AWOL. Patient began to decrease in LOC (over about 10 mins). Manual BP was evaluated at 48 systolic. IVs opened wide. Patient moved to another room, doc called, BP re-evaluated at 135/100, patient is now slightly responsive. Several minutes later patient is unresponsive, and incontinent of feces with a SBP of 66. Unresponsive to what .. verbal or painful stimulation ? So I ask you do you do you think this last drop in BP and LOC, could be a result of a Vaso Vagal response due BM ? Then what was stool like ? Diarrhea, runny loose any melena or coffee ground ?Complicating the presentation is the "use" of stool softeners its curious that pt. is using them, as antibiotics typically cause diarrhea, not the other way around. With your fluid bolus of 500 cc and an improvement in BP associated with increased LOC could be indicative that this patient is in need of fluid resuscitation ? I think this may be the direction your taking this scenario, I cannot "Hang my Hat" on anything with info provided. Ok so his/her working dx svp. Without any labs i.e. Lytes, hematocrit, CBC, would really be very helpful here to suggest any Dx and "STAT LABS" can get this info pretty dang fast. Did the MD have that info or was the DX made purely on Clinical Evaluation ? Its pretty hard from the picture you paint to get a "working dx" other than suspected volume depletion, with rapid variance in LOC with associated variances in BP. cheers