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FYI guys, if you remember simple anatomy, you'll know why increased ICP can't cause eyes to bulge out.

"Anyone have an 'eye pushing' protocol?" Dwayne, I'm in California--the bastards took that away from us too!

As you describe it, this kid is obviously pretty septic. Not a good thing, esp. considering it's only 2 months old. When I did my L&D clinicals a while back, I asked my instructor (long-time L&D nurse) what would cause an infant to have periods of apnea. She said with premies it was typically apnea of prematurity (excuse the Wiki reference, but it's a pretty good basic intro: http://en.wikipedia.org/wiki/Apnea_of_prematurity). She said that for babies born at term, the cause is likely sepsis. In this case the baby is obviously septic. As you may know, the doc was doing a spinal tap to r/o meningitis. Hopefully the seizure was due to the spiking fever and not meningitis or encephalopathy. Afterwards, did your supervisor ask you to take antibiotics? A few years back, I saw what was most likely apena of prematurity in a premie I transported to the ER. Scared the crap out of me (and mom). Baby stoppped breathing, went blue, bradycardic, but then pinked up right away with stimulation. Thanks for sharing this interesting case!

Yeah, I agree with what you're saying, but I just don't see the need to give the fluids in the ambulance. I think you're thinking about this more from a hospital perspective. The BP is not critical, and in my 15 minute ride to the ER, I'm not going to cure sepsis. If my diagnosis is wrong--not having CXR, labs, and time to scratch my chin and think about it--I could make this patient a whole lot more sick by giving fluids.

You didn't do anything wrong. However, if the fire department is stupidly insisting on an AMA, why not just do one and make everyone happy? And if the patient refuses to sign one or be evaluated, just write one up anyway and document what happened.

I think it's wonderful that you are considering a career in EMS! As much as I like being a paramedic, I would suggest to anyone considering EMS vs. fire vs. police that the best job may be in police work It is much easier to get a job as a cop than it is to get a job as a firefighter. Once the economy improves, it won't be difficult to get a job as a paramedic for a private ambulance company, but you will never make much money. To become a paramedic also requires more education and experiences, and you'll have to support yourself for a year while you're in paramedic school. As a cop, you'll have great pay and benefits, not to mention a great pension, and if you work for a big department, you'll have many chances for advancements or doing various jobs within the departments. Corrections pays great in CA, and I know a few people who've done it. But is that really the job you want to be doing for the rest of your life? I should state to obvious which is that right now no one is hiring cops, firefighters, and even private ambulance paramedics. It may take a few years for the CA economy to turn around, but once it does there will be a great demand once again. Vent makes an xlnt suggestions about taking an anatomy/physiology course first. I would suggest that you also take an EMT course afterwards. This will give you an idea of whether you find medicine interesting, and once you get your EMT cert, you may be able to find a job working on an ambulance, though most likely it will be only doing non-emergency interfacility transports. If you find that you don't like medicine or you don't like working on an ambulance, you can consider becoming a cop, and your experience as an EMT will be well regarded. I would also very strongly suggest that you finish your bachelor's degree as that is now sought after by most police departments.

FYI, I meant to post this on the news discussion board; not sure why it ended up here. What do I find wrong with this article? Is it really such a big deal that, in a department as big as LAFD, there was an incident of one person insulting another and pushing a bench towards him, or someone saying a racial epithet (though apparently not directed at anyone) and not being suspended for it, etc? This stuff happens in any large organization. Apparently the LA Times thinks anything related to criticism of LAFD or LAPD is big news. When I read the headline and saw it on the front page, I thought that there was some big scandal brewing. Dust, I'm sure you'll disagree with me.

Sorry to be bringing back to life this old thread, but I've been so busy with school that I haven't had a chance to read EMT City all semester. I'm curious about what some of the posters have said about giving fluids to this patient en route to the hospital. Personally, I would not be comfortable doing that. How can we be sure that this is just sepsis? How do we knwo that the fluid is going to stay where we want it--in the blood vessels and not go into the lungs? Also, if we gave a bolus and then re-evaluated the patient, how would we do that when she already has wet lung sounds all over. What do you guys think?

"Chuck Norris’ tears can cure cancer. The only problem is, Chuck Norris doesn’t cry." LMAO

I can't believe the LA Times puts chickenshit stuff like this on the front page.... http://latimesblogs.latimes.com/lanow/2010/04/la-fire-department-audit.html City audit faults L.A. Fire Department's disciplinary process April 15, 2010 | 6:00 am Despite repeated vows to reform the way it handles costly discrimination and misconduct complaints, the Los Angeles Fire Department relies on a disciplinary system plagued by poor documentation, uneven punishment and a lack of clear guidelines, according to a city audit. The allegations outlined in the 220-page report mirror findings that have been raised repeatedly in city audits dating from 1994. The cases cited in the study occurred between late 2007 and last year -- after Mayor Antonio Villaraigosa and top fire officials vowed to change department culture in the wake of legal payouts that had cost taxpayers millions of dollars to settle claims of harassment, retaliation and discrimination. The audit, conducted by the Fire Commission's office of independent assessor, credited the department with making improvements but noted that it has a way to go to address longstanding problems in its investigative process. The report was presented Tuesday to the Fire Commission. Among the problem cases cited in the latest audit: •A firefighter told two Jewish firefighters, "I'll stick you in an oven," and later pushed a firehouse bench toward one of the men after he filed a discrimination complaint. A station captain failed to take action after being told of the comments, and department investigators failed to fully investigate the incident involving the bench. •A firefighter used a racial epithet in front of several firefighters who were having dinner with an African American colleague after a department golf tournament. The firefighter should have received time off but was only issued a written reprimand. •Department investigators engaged in alleged misconduct when serving a subpoena for confidential medical records during a disciplinary probe. The audit recommended that the department immediately stop seeking investigative subpoenas, a practice that exposes the city to legal liability, until a formal policy is written. •An off-duty paramedic was caught by police with a prostitute in his car as the two appeared ready to engage in a sexual act. Department investigators conducted a cursory interview and failed to file adequately researched reports. In the end, the paramedic received six days off. Battalion Chief Ronnie Villanueva said in an interview Wednesday that the department acknowledged the problems outlined in the audit and is working with the Fire Commission to reform its investigation and disciplinary system. "We embrace the report," said Villanueva, a department spokesman. "We need to change the way we do business. We need to improve our process." -- Robert J. Lopez

We discussed this story on the forum about a year ago. I used to work in Kern County. Don't remember all the details, but basically a medic showed up and the cop told him, "He's just drunk. He's going with us." The medic made patient contact but apparently also thought he was just drunk. He didn't do a proper assessment. One story I heard was that the medic claimed he could not do a proper neuro assessment because the patient was handcuffed. I'm not sure if this is really what he claimed or if that was the case then why he didn't just get the cop to uncuff him. Again, this is just what I heard and I'm not in on all the facts of the case. The medic took off, and sometime later a nurse from the hospital came by because she recognized the doctor. She realized he was having a stroke and had PD call for another ambulance. The lawyers will still have to prove that the delay in medical care would have made any difference in this guy's outcome. That doesn't seem very likely if he had a bleed, which is what I heard he had. Regardless, it's really tragic that this highly skilled doctor has become disabled. If I remember correctly, he was specialized surgeon of some kind.

Dust, that was probalby a Rural Metro or some other private ambulance. SD Fire doesn't have their own ambulances anymore.

Have any of you heard of this new device, a S.A.L.T. airway? If it works as advertised, it could be really useful. They claim a 98% success rate with ET intubations. http://www.mdimicrotek.com/prod_salt.htm

Here's the trailer...It's a bit melodramatic, but the movie isn't like that.

Have you guys seen "The Diving Bell and the Butterfly"? It's true story about a glamorous French magazine editor who has "locked-in syndrome" after suddenly suffering from a massive stroke. He dictates a book by blinking his eyes to a nurse. It's a beautiful movie--I recommend it highly.

http://www.guardian.co.uk/world/2009/nov/23/man-trapped-coma-23-years Car crash victim trapped in 'coma' for 23 years was consciousParalysed patient could not move or communicate with doctors until Belgian neurologist tested new brain scanner For 23 years Rom Houben was trapped in his own body, unable to communicate with his doctors or family. They presumed he was in a vegetative state following a near-fatal car crash in 1983. But then doctors used a state-of-the-art scanning system on the brain of the martial arts enthusiast, which showed it was functioning almost normally. "I had dreamed myself away," said Houben, now 46, whose real "state" was discovered three years ago and has just been made public by the doctor who rescued him. Steven Laureys, a neurologist at the University of Liège in Belgium, has published a scientific paper saying Houben could be one of many falsely diagnosed coma cases around the world. Houben is being cared for at a facility near Brussels and now communicates via a computer with a special keyboard activated with his right hand, which is capable of minimal movement. He said his body was paralysed when he came round after his accident. Although he could hear every word his doctors spoke, he could not communicate with them. "I screamed, but there was nothing to hear," he said, via his keyboard. Houben then suffered years of being effectively trapped in his own body as care personnel and doctors at the hospital in Zolder tried to communicate with him, but eventually gave up hope that he would ever come round. The moment it was discovered he was not in a vegetative state, said Houben, it was like being born again. "I'll never forget the day that they discovered me, it was my second birth." Experts say Laureys' findings are likely to reopen the debate over when the decision should be made to terminate the lives of those in comas who appear to be unconscious but might have almost fully-functioning brains. Belgian doctors used an internationally accepted scale to monitor Houben's state over the years. Known as the Glasgow Coma Scale, it requires assessment of the eyes, verbal and motor responses. But they failed to assess him correctly and missed signs that his brain was still functioning. Laureys, who is head of the coma science group and neurology department at Liège University hospital, concluded coma patients are diagnosed falsely "on a disturbingly regular basis". In around 40% of cases diagnosed as vegetative, more careful examination shows there is still some level of consciousness. He examined 44 patients believed to be in a vegetative state, and found that 18 of them responded to communication. "Once someone is labelled as being without consciousness, it is very hard to get rid of that," he told Spiegel magazine, calling for a systematic overhaul of the methods of diagnosis. Laureys said patients who are not fully unconscious can often be treated and are capable of making considerable progress. Around a fifth of patients who suffer serious head and brain injuries spend more than three weeks in a coma. Of those, between 15% and 25% are, technically speaking, still alive but remain in a state of unconsciousness, never to wake up.

P Instructor wrote, "If this was a true situation, your knowledge and experience would hopefully promote a fast clinical decision to the proper treatment regime. One must remember that not all thought out processes will work, and you must always be prepared for the possible unwanted outcome." Well said.

Guys, this is a fictional scenario. As I stated in my original post, I did have something similar in my experience. I saw a patient with a massive MI go from a sinus brady rhythm to what was probably VT but at a rate of about 120. I didn't do anything for about a minute, and the patient self converted back to a sinus rhythm. I'm just trying to get your opinion on what you would do in the scenario as presented. Good discussion so far!

Okay, to clear things up, let's say that after you have resuscitated the patient, he has barely palpable pulses. You're on your way to the ER, busy hanging a dopamine bag and probably doing ten other things at once, and you see him suddenly going from a narrow complex sinus rhythm at a rate of 80 into a wide-complex tachycardia that looks EXACTLY like VT. He still has barely palpable pulses. The heart rate is 120.

I've been discussing this scenario with a co-worker. I'd like to know what you guys would do: You have resuscitated a patient who was in PEA. He's now in a normal sinus rhythm with pulses. As you are transporting the patient, he goes into a wide-complex tachycardia that looks exactly like VT (perfect sine waves), but at heart rate of 120, and he still has pulses. Would you cardiovert? My thinking is that no, you should not, because you can't be sure if it's VT, and that even if it is, the rate isn't so fast as to affect cardiac output. I actually had a similar scenario where I had a critical patient who went from a brady sinus rhythm with narrow complexes to a wide-complex tachycardia at a rate of 120 (with pulses). I held off doing anything and about a minute later the patient converted back into a sinus rhythm. My co-worked argued that if the apparent VT was sustained, it should be cardioverted because it could soon deteriorate into VF or a much faster VT. What do you guys think? Let's say you have no access to a 12 lead.

Wow, 21 pages on this! I haven't yet seen this show, and I don't really plan to. No doubt it'll be gone after a few episodes. I am surprised how much money they put into advertising. Here in L.A. there's ads for it all over the place.

"Hypervolemic hyponatremia occurs when sodium stores increase inappropriately." I don't get this. Wouldn't this by hypernatremia?

Thanks Vent!

True, but he does also mention that the ETCO2 and PaCO2 won't match in drowning victims. He doesn't really go into other types of non-trauma cases. Paging VentMedic....