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To answer the question about pedal pulses, you get the volunteer on the fire crew to take off the patient's shoes :x. Good pulses and cap refill. Anything else you guys would like to check?

I anticipated a lot of discussion regarding this patient's BP, so that's great. I think there are misconceptions about hypertensive emergencies among us providers. I certainly have been misinformed about this subject in the past. For more info, check out these xlnt articles: http://www.emedicine.com/emerg/TOPIC267.HTM http://en.wikipedia.org/wiki/Hypertensive_crisis

More great responses! You guys are right on it. I also once had an elderly patient who was complaining of back pain from a previous injury who turned out have an abdominal aneurysm that hadn't been previously diagnosed. (His back pain, however, was unrelated to the aneurysm). To answer the question about the Miami stroke test....I'm not familiar with that one, but here's what you find on the Riverside Stroke Test (:wink: ) He grips your hands with equal strength. No facial droop. No slurred speech.

I agree with Dwayne. You really have to question this study. Yes, I think we all agree that with penetrating trauma we need to not do IV's on scene and stupid stuff like that. There may be some things that slow us down that a non-EMS person would not have to deal with, such as spinal immobilzation (in the few cases of penetrating trauma that require it) and our response times. However, we benefit trauma patients by knowing where to take them and having a trauma team ready and waiting for us before we arrive.

Note that I just made an edit to my previous post about checking for orthostatic changes.

Here are a few discussion points that I think may be interesting to consider. (These aren’t my opinions, just things that may help the discussion along.) 1) This patient doesn’t want to go to the ER. Would you feel comfortable not taking him? Should someone with non-traumatic back pain always be taken by ambulance to the ER? Should they go to the ER at all? 2) If a person with back pain were to ask you what the hospital is going to do for them besides give pain medication, what would you explain? 3) If his BP was lower, would you feel more comfortable not taking him to the hospital? Is his BP symptomatic of anything? If he had no back pain nor any other symptoms, would you try to talk him into going to the ER because you were concerned about his elevated BP? Will the ER do anything to lower his BP if he’s asymptomatic? 4) Is his ECG a concern? 5) What else would you like to know about this patient? What further assessments are needed?

All great questions so far! Orthostatic changes? It's too painful for him to sit up, so you are unable to check. No, he doesn't have any other pain, just the pain in his lower back which he describes as sharp, non-radiating, 10/10. He also has some numbness in both legs and they feel weak. He has a hot pack on it and says that's helping. Yes, he's taken some Tylenol. No history of drugs/alcoholism. He has had back pains like this before but has never had any traumatic injuries and has never seen a doctor. No recent illness. He does not take herbal remedies. He says he threw his back out when he was reaching down to pick up a bag of fertilizer. Sorry, I don’t have a 12-lead for you, so I’ll just have to describe what you see. It shows a normal sinus rhythm with a few PVC's (less than 10 a minute). No T wave or ST changes.

Here's what you see on your monitor (3 lead): http://library.med.utah.edu/kw/ecg/mml/ecg_unifocal.html

You are called to the home of a 55 y/o male who is having back pain. The home is well kept and you are greeted by the patient’s teenage daughter. She explains that her parents don’t speak English but that she'll translate. The patient is covered with a blanket lying on a couch. With his daughter translating, he says that he was working in the yard when he threw his back out. He walked in and laid down on the couch. He has a bad back and he always feels better with a few days of rest. He says he doesn’t need any medical help. The family called 911 anyway because they know he’s stubborn and they didn’t want to see him suffer. They would like to know if there’s anything you can give him for his pain. History: None. “He’s never seen a doctor in his life.” Meds: none Allergies: none that they know about. His vitals: GCS: 4/6/5 Skins: warm, slightly diaphoretic, pink Pulse: 96 strong & regular Clear bilateral breath sounds with a respiratory rate of 18 PO 98% on RA BP: 210/104

Since this device looks to be very similar to the HANS device now mandatory in all professional autoracing groups, you might want to consult with medics who have experience working autoracing events.

You know what makes for an xlnt pelvic splint? The thigh straps used with the Sager traction splint (I think the Hare splints may have them too). One isn't long enough to fit around the pelvis, so you take two and put them together with their velcro attachments. Try it yourself sometime--put one around your pelvis and you see that's is really easy to put on and keeps the pelvis really secure.

Ah man, you're gonna make me do all the work?! Well alright.... Is this our only patient? Are we sure that his passenger isn't wrapped around some other telephone pole? Describe the mechanism more. How fast was he going? How much damage? Passenger-space intrusion? Belts? Airbag? Wheel damage? Windshield? Etc........... We put the patient in spinal immobilization. Any neck pain? Good motor/neuro x 4? Is the patient oriented? Pupils? Smell of alcahol? Any LOC? We ask him how the accident happened. Does he have any complaints? Pain? SOB? If he is altered or has significant injury, we put him on a mask right away. What are his breath sounds? Rate and tidal volume? Skin signs? Radial pulse rate/character? We do a rapid head to toe exam. Any obvious findings here? After he's extricated and in the ambulance, we get vital signs and do a complete physical exam. Med history? Meds? Rhythm? Blood sugar? We head to the trauma center and start 2 IV's. Now what?

I'm thankful that I have a job were I can watch "Columbo" on TV and get paid for it. :wink: I'm thankful that I have a job that I find rewarding and that allows me to help people in small ways.

Hey Anthony, Great scenario so far. I think we're all on the same page about basic treament (C-spine, etc.), so can you give us his vitals? GCS? Anything more you can tell us about mechanism? He is the only patient, right? So far this seems pretty straightforward, but I'm waiting for the zebra. :wink:

Hey Anthony. I'm sure you get lots of pratice with gun-shot victims in LA. :wink: "Penetrating injury represents a special consideration regarding the potential for spinal trauma. In general, if a patient did not sustain definite neurologic injury at the moment that the trauma occurred, there is little concern for a spinal injury. This is because of the mechanism of injury and the kinematics associated with the force involved. Penetrating objects generally do not produce unstable spinal fractures as does blunt force injury because penetrating trauma produces little risk of unstable ligamentous or bony injury A penetrating object causes injury along the path of penetration. If the object did not directly injure the spinal cord as it penetrated, he patient will not likely develop a spinal cord injury." This is from my PHTLS book, and it's nothing new. I took that class nearly 5 years ago. Rather than spending several minutes on scene putting your patient in spinal immobilization, you can lift the patient onto your gurney and be off scene in less than a minute. You are not opening yourself up to liability by doing this as long as the patient has no neurological deficits. You are strictly following the guidelines of the American College of Surgeons. There is nothing in the LA County protocols that contradicts PHTLS guidelines.

I hate having my morning coffee break interrupted. Can't my patients find a better time to have a heart attack?

I don't think it was a miracle either, just an extremely lucky guy.

Great topic, guys. I learn something new every time I log into this forum. I can see why the doc wasn't worried, but what's up with the nurses? I remember once I brought in a patient with ST elevation and I showed his ECG to the charge nurse and another nurse and they did nothing about it. I showed the strip to a third nurse, who then gave it to the doc. As soon as he saw it, he immediately made the patient a STEMI alert. I think that some nurses don't pay much attention to an ECG unless they see the computer's "Acute MI alert" message.

I commented on your scenario. The rate (just under 150) was a little slow for VT, and the patient was totally stable, so I said that I would go with a very conservative Tx (no drugs, no shock). Things just didn't quite add up, so I didn't want to treat the rhythm like it was VT. Now the question is, what would I have done if the patient had been presented as being unstable? To be honest, in that case I would have shocked her. The patient, as you presented, went from a narrow-complex bradycardia to a wide-complex super-tachycardia. If it looks like a duck, walks like a duck....

Here's an interesting statistic: "More than 70% of patients who die from a pulmonary embolism are not suspected of having had one before death." (Egan's Fundamentals of Respiratory Care)

From what I've read, death from a massive PE is not due to hypoxia but from cardiovascular collapse. I've looked into this with several sources, including a book that I'm reading now called "Egan's Fundamentals of Respiratory Care." To quote from the book: "Death from massive pulmonary embolism is the result of cardiovascular collapse rather than respiratory failure...Pulmonary hypertension occurs when 50% of the pulmonary vascular bed has been occluded. To maintain the same flow at a higher pressure, the right ventricle must work harder. The final result is an increase in the right ventricular work, causing the right ventricle to become dilated and ischemic...the right ventricle fails with consequent hemodynamic collapse." So this is why I'm thinking that you ought to see JVD intially. I don't however see this listed as a common sign in the other sources that I've looked at. In an Emedicine online article that I read, it makes no mention of JVD. [Common signs are dyspnea (60% of cases), chest pain (20%), rales (50%), fever (40%), cyanosis (20%) ]. I can see how eventually you could get failure of both the right and left ventricles, but wouldn't you at first see signs of right-ventricular failure? There are two other things that I'm wondering about. Why do so many patients with a pulmonary embolism present with rales? Is it due to the subsequent failure of the left ventricle? What causes wheezing in a PE? Is it due to fluid in the lungs, or some other mechanism?

Why is JVD not a common sign in a patient with a massive pulmonary embolism considering that such a a patient would be suffering from an acute failure of his right ventricle?

VD Cavey, Great to have another European contributor on this forum! You'll have to tell us all about what EMS is like in Belgium.

Here's a video from Fox news about a cardiac-arrest save. The guy was found dead in bed and was in a coma in the hospital for 3 weeks before waking up. http://cosmos.bcst.yahoo.com/up/player/pop...13&src=news

For a short while we used to have one of those European-style, Mercedes-built ambulances (I think they were badged as American Le-France). I really liked it but most people didn't. They thought looked it too wimpy with it's narrow body and little wheels. America right now is really in love with the rugged, bigger-is-better look. I remember the designer of the current Ford F-150 truck talking about how his design team wanted to make the truck look bigger and tougher than the old model. It's kinda like how in the early 60s designers were all about making cars look longer, wider, lower. I think this mentality is slowly changing as we are becoming more worried about the environment and gas prices.