zzyzx

Look, this woman drank hydrochloric acid. Do you really think she is responsible for her actions? Just feel sorry for her, and be thankful that you are not her.

Anybody from EMT City going to the EMS conference/exhibit in Vegas in October?

I believe that AMR will not hire you if it's been less than 3 years since your DUI. Other ambulance companies probably have similar policies. You should call their employment office and find out for sure. Not sure about fire departments. I don't think the DUI would exclude you since by the time you become a medic it'll have been many years since. But again, you should check around.

Nope, no peaked T waves. While I was waiting at the ER, I looked down at the monitor and saw a BBB. I thought she had been in a normal sinus rhythm with no block before, but I wasn't sure if I remembered correctly. Her son came in and started asking her about her dialysis, and then I remember that I'd never asked her about when she'd last gone to dialysis. She wasn't very forthcoming, but it turned out she had not been since Tuesday. It was only at this point that I connected the dots and realized she was probably way hyperkalemic. I went searching for the charge nurse and told her, "Hey, I didn't realize this until just now, but she's missed two of her dialysis appointments, and she's in a bundle-branch block." The ER was busy with a 2 y/o respiratory arrest that had come in just after our arrival. The charge nurse told me she'd get another nurse to come triage our patient, but he never came. We waited for a while longer, and now when I when I looked down at the monitor, her ECG basically just looked horrible. Our patient still had no complaint and was in no distress. I went looking for an ER tech so I could at least do a 12-lead (nearly everyone was in another room working on the 2 y/o), but fortunately at this time a nurse I get along with really well walked through the ER doors to start his swing shift. I showed him the strip and told him what was going on. All the beds were occupied, but he pulled one patient out of their bed and put him into a hall bed. He then got an order from the doc for 100 mg calcium before we even did the 12-lead. I did the 12-lead using the ER's machine, and it showed a BBB but only peaked T waves in two of the anterior leads. I wish I had taken a copy so I could post it. From what I understand, peaked T waves are more likely to show up at an early stage, while a BBB develops later. Anyway, my patient had a good outcome, but she could easily have coded on our gurney. I felt stupid for not having immediately asked about her last dialysis and not immediately connecting the dots when I saw the BBB. I'll try to follow up with the nurse and let you know just how high her K+ ended up being.

I don't do 9 leads with my 3-lead monitor because I don't believe that I would get the same diagnostic quality as using a monitor set up to do 12-leads. I've used 12-lead monitors (Lifepak 12's) a lot in the past at my old service. We're supposed to be getting 12-leads sometime late this year.

Xlnt question, Christopher! Major kudos! That was one of my dumb mistakes. I was told her dialysis schedule, but did not immediately ask her when she last went. I found out much later that she had missed her last two appointments. Her only complaint is generalized weakness. No chest pain, SOB, etc. She is in no distress, just tired.

I realize that there are a few other scenarios running this week, but I have to share this one with you. This was the most interesting call of a very eventful weekend, one where I ran an eclamptic seizure and a 35 y/o full arrest at a dentist office. I really dodged a bullet on this call due to two dumb mistakes that I made. You get called to a church on Sunday morning for a syncope. You arrive to find a 55 y/o heavyset woman sitting in the choir pew. There’s a little bit of sweat on her brow, but she doesn’t appear to be in any distress. “I was standing up and felt like I was gonna pass out, but I sat down on the floor before I did. I was too weak to get up by myself, but my friends helped me.” History of dialysis. She goes Tuesday, Thursday, and Saturday. Only other history is hypertension, which was the cause of her kidney failure. (Sorry, but I forgot her meds.) Her vitals are within normal limits. Lungs are clear and sats are normal. So is her blood sugar. Normal sinus on the monitor. (Sorry, but my system only uses obsolete 3-lead monitors.) She is weak, but with assistance you are able to walk her down the three steps of the choir pew and onto your gurney. What else you would you like to know? Treatments? This won’t be to hard for you guys to figure out, but it’s a very interesting and, I think, educational scenario. By the way, my initial impression was that this was vaso-vagal (near) syncope. I was wrong.

One of our VST's developed a spontaneous pneumo while at work. He didn't have Marfan's syndrome, but did have a family Hx of relatives developing pneumos.

I said before that it's textbook MI, but now that I think about again, it's not. I would we worried about the following possibilities: 1) MI 2) PE 3) aortic aneurysm 4) drugs 5) cardiac contusion. Any pain on palpation? Broken ribs? Bruising?

If I ran this call for real, I would probably put the blood streaks down to 1) his surgery 2) his cancer 3)pneumonia 4) pulmonary embolism (less likely). But of course I know ERDoc isn't going to make it so easy. For now I would just transport ALS, and I'll be sure to keep listening to his lung sounds in case something changes.

I just found a good article about anaphylaxis that also discusses the use of glucagon with patients taking beta blockers.... http://www.aafp.org/afp/20031001/1325.html

CT scans cause cancer in one in a thousand patients? That's a great risk considering how common CT scans are. I've had one, and so have all the other millions of people who've gone to the ER for kidney stones. I hadn't realized that there is such great risk involved with CT scans. Are those numbers controversial? Have we seen a big increase in certain cancers since the introduction of CT scans?

Great scenario! I've never heard of glucagon being used for anaphylaxis. I'll have to look into that. Learned something new.

A 12-lead would be nice too; see if she's got any widened complexes. Can't be sure that this isn't a tricyclic OD since she may not have told her mom that she's on anti-depressants.

Do we have a 12-lead? Any recent illness? Chest pain? Complete medical Hx? Vital signs?

I'm coming to this a little late...so far it sounds like a textbook MI. But of course I know ERDoc has something up his sleeve. Does he feel hot? Can we do a drug screen on our mobile ER? What does the chest Xray show? I'm worried about an aortic dissection.

"Hello, Sir. My name is Nigel. I'm an ambulance attendant. Yawright?"

It can be confusing when you see a pacemaker pacing at rates above 100. But you'll always know it's a pacer rhythm and not VT if you see pacemaker spikes. Note that on some monitors, like the Lifepak 12's that we use, you won't never see pacer spikes until you set the monitor to mark them.

In the three California counties that I've worked in, no one ever tells the patient up front what the cost of the service may be, unless they ask. I was listening to a radio talk show the other day. They were discussing EMS. One person called in saying (I'm paraphrasing), "I didn't have insurance or a regular doctor, and I was at the pharmacy seeing if I could get something for some abdominal pain I was having. The pharmacist suggested I just call 911. I called them and asked the dispatcher if I should go to the hospital, and she said, 'Don't worry, I'll get an ambulance to help you out.' A little while later, all kinds of people showed up, firefighters, paramedics. The hospital was only two blocks away and I could've just walked there, but the ambulance people said, 'Don't worry, we'll just take you there.' Well, a month later I get a bill for a thousand dollars from this ambulance company. I was really upset. It seems to me like they are just concerned with trying to transport as many bodies as possible so they can up their profit."

Congrats Chbare! It indeed was Guillain-Bare syndrome. I ran this call two years ago, and to be honest I really thought this guy was faking. I hadn't heard of any disorder could cause you to wake up paralyzed. Here's more info on Guillain-Bare syndrome: http://en.wikipedia.org/wiki/Guillian_Barre_syndrome

No, he hasn't been overseas. Nothing remarkable about his diet. No diaphoresis. His skins signs are normal, and there is no edema. He doesn't appear febrile.

I'm looking for articles on the use of post-resuscitation drips (i.e., amiodarone, lidocaine) after a patient has been cardioverted out of V tach. I know this is a pretty universal practice, but just wondering if it's evidence based.

Nope, he didn't eat any chicken. His K+ is within normal limits.

I'm wondering if any of you guys are instructed to or even allowed to tell your patients of the possible costs of the ambulance transport if the patient never asks you. For the services that I've worked for, we would only tell the patient if they specifically asked us. A lot of people assume that ambulance transport is a free, just like calling for a fire engine or a police car. It seems that we are doing them a great disservice by not telling them of the costs if they have no insurance. On the other hand, if we did tell them, it would seem like we were trying to talk them out of it. I have a related question for those of you who work in the ER. What happens to someone with no insurance and no way of paying for a large hospital bill? Will the hospital always send the bill to collection?

To answer your questions... He doesn't have any numbness or tingling. He does have some aching pain in his legs. Positive pulse, motor, sensation, but he is very weak in his legs. No back pain. Recent viral illness? He says he felt like he had the flu a few days ago, but now feels fine. Does not appear to be febrile. No difference in skin signs between upper and lower body. He was sleeping on his side. Family/social Hx? He's a 20 y/o Asian male. He lives with his parents, who are non-English speaking Vietnamese. The family is poor. Your partner suggests that maybe the patient is faking his symptoms. The patient does not seem to be in any distress and is answering your questions quite calmly. He doesn't complain of any other symptoms besides what he's already told you.