akroeze Posted October 31, 2007 Posted October 31, 2007 You and your partner have had a nice shift so far and are just sitting down for a well deserved lunch when the base pager goes off. 1234, code four to XYZ Nursing home, code four You sigh as you quickly go through the grieving process at your loss of lunch. Having gone through all the stages of grieving in seconds you head to you and your partner head to your truck and book on the air. 1234, you're code four to XYZ Nursing home for an 87 y/o female patient who has been unwell all day, decreased LOA with a heart rate of 40 and a blood sugar of 16.1mmol/L (289.8mg/dl). Also has cyanosis to the legs. As you are both Primary Care Paramedics on this truck you ask if ALS backup is available. Dispatch advises you that the only ALS truck that has a chance of getting to you is on an off-load delay at the hospital but if they get clear she'll send them your way. It's a quick 3 minute response to the nursing home and you're met at the elevator by the RPN. He tells you he is a part time nurse who doesn't normally work this floor. When he went in to assess Ms. Johnson he was concerned by her decreased LOA. The health care aides said she normally isn't totally responsive but he trusted his instincts and did a full assessment. He then decided to continue to trust his gut instinct and called EMS. As you eneter the room you see the patient supine in bed, she seems to be breathing slightly fast and on a scale of looking not sick to sick she would rate a sick. What do you do? This is a scenario one of my instructors put to our ACP class today and it is one that a crew did the other day. I have taken some creative liberties with the backstory but the facts are unchanged from the real case. Although this crew never had ACP backup, I'd like to know what you'd do at both a PCP and ACP level. For a rough guide for those who aren't familiar: PCP * Glucometer * S-AED * 12-lead * SpO2 * Epi 1:1000 * Nitro * ASA * Glucagon * Oxygen * Ventolin (Salbutamol, Albuterol) * Glucose paste ACP * advanced airway management equipment * orotracheal and nasotracheal intubation equipment * lighted stylet intubation equipment * LMA's * SPO2 monitoring * Side stream ETCO2 monitoring (capnography and capnometry) * mechanical ventilation * laryngoscopy and removal of foreign body obstruction using MacGill forceps * intravenous therapy * 12 lead ECG interpretation * needle thoracostomy * intraosseous and external jugular IV starts * manual defibrillation, synchronized cardioversion and external transcutaneous cardiac pacing * treatment of cardiac emergencies according to Heart & Stroke Foundation Advanced Cardiac Life Support (ACLS) guidelines * administration of the following emergency medications: Adenosine, Amiodarone, ASA, Atropine, Dextrose, Diazepam, Dimenhydrinate, Diphenhydramine, Dopamine, Epinephrine, Fentanyl, Furosemide, Glucagon, Lidocaine, Morphine, Naloxone, Nitroglycerine, Salbutamol, Sodium Bicarbonate, Midazolam.
Freaknuggetz_chick Posted October 31, 2007 Posted October 31, 2007 no PCP's up to bat yet...? tsk tsk
akroeze Posted October 31, 2007 Author Posted October 31, 2007 You don't have to be a PCP to do this.... it's open to anyone, so give it a shot! I just want to know what you'd do at a PCP and an ACP level.
AnthonyM83 Posted October 31, 2007 Posted October 31, 2007 Hello, hello, I'm Anthony, I'm an EMT, CAN I HELP YOUUUUU? Ask someone to look up her medical history sheet, last vital signs, last meals, medicines, allergies. Go ahead an do an assessment. What's her Awareness/Orientation, Pupils, Skin, Pulse, Respiratory Rate, Blood Pressure, Blood Glucose, Oxygen Saturation? Physical findings? Airway, breathing (lung sounds), circulation quality (distal)? Pedal/Dependent Edema? Jugular Vein Distension? Tracheal Deviation? Stoma? Medical Jewelry? Surgery marks? Can you rule out any trauma? Does she have a roommate who might shed light on anything? Will looking around the room tell you anything? Can we find out what her normal mental status and mobility level is from anyone else? For now, run the 12-lead.
akroeze Posted October 31, 2007 Author Posted October 31, 2007 Hello, hello, I'm Anthony, I'm an EMT, CAN I HELP YOUUUUU? Ask someone to look up her medical history sheet, last vital signs, last meals, medicines, allergies. Go ahead an do an assessment. What's her Awareness/Orientation, Pupils, Skin, Pulse, Respiratory Rate, Blood Pressure, Blood Glucose, Oxygen Saturation? Physical findings? Airway, breathing (lung sounds), circulation quality (distal)? Pedal/Dependent Edema? Jugular Vein Distension? Tracheal Deviation? Medical Jewelry? Surgery marks? Can you rule out any trauma? Does she have a roommate who might shed light on anything? For now, run the 12-lead. You quickly assess her responsivenes and get a GCS of 13 (3-4-6). Airway is patent and there is no JVD or edema. While you take a pulse and SpO2 reading your partner gets a BP and resps. HR: 40 weak/regular BP: 98/68 SpO2 RA: 88% R: 24 T: 38.1C tympanic A/E clear = bilat The nurse hands you a history sheet which states increased cholesterol, NIDDM, Heart bypass in 2000, dementia. You throw the limb leads on her and get a sinus brad, no ectopy noted. Same on the 12-lead. You grab your glucometer and find it to be 26.1(469.8 ). There is no known history of trauma and she is in a private room, no room mate.
akroeze Posted October 31, 2007 Author Posted October 31, 2007 Sorry, forget to give you: NKA Nitro prn Lipitor Glyburide Metformin Allopurinol
AnthonyM83 Posted October 31, 2007 Posted October 31, 2007 Let's increase her FiO2 (thank you Dust & VentMedic) with O2 by NRB. Any other signs of hypoxia? How does the O2 affect her saturation and other signs. Has she been compliant with medications? When was the last time she looked normal (is it in the chart?)? Chest pain? SOB? Speaking full sentences? Equal grips? Nausea? Regular bathroom stuff? Skin signs? Pain anywhere? I'd start getting her loaded up, high Fowler's position if SOB. So far, I have what looks like noncompensated septic shock...maybe some pneumonia? (I'm bad at the possible/suspected diagnosis part.) Sugar high despite her two meds. Do detailed physical enroute. Reevaluate. Monitor Airway and mental status. Can we compare to her current condition to her normal vital signs and condition using her chart?
AnthonyM83 Posted October 31, 2007 Posted October 31, 2007 PS If I were ALS, I suppose I'd give her IV NS. Interpret her 12-lead. Consider atropine. But need more.
akroeze Posted October 31, 2007 Author Posted October 31, 2007 The patient has received all of her meds. The patient has very severe dementia and unfortunately can't tell you much about her symptoms. You put the NRB on the patient and transfer her to your stretcher. As soon as she hits your mattress you hear the QRS beeps on your monitor jump in rate. You turn to look at it and find the following rhythm: (This is the actual strip from the call) Now what?
AnthonyM83 Posted October 31, 2007 Posted October 31, 2007 Ooh, I just read about this one last night, so I'll venture forward. VTach at about 150. I'd give 150mg amiodarone over 10 minutes and reevaluate rhythm and VS. I'd consider synchronized cardioversion, next. And of course confirm pt still has a pulse. I'm being cookbook at this point, now.
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