FL_Medic Posted March 7, 2009 Posted March 7, 2009 We have all had those calls that we wish we could have back. The first call that made you pucker up, and lose your ego. The call that you looked back on, realizing you missed something. When we have a call with an abnormal presentation, or just an interesting call we frequently research it after the fact. Some of us become near experts on a certain topic because of a bad or interesting call. Please use this thread (I hope there isn't like a whole section devoted to this already that I missed) to discuss these in a case review mannor. Be as specific as possible. Give a brief, but detailed history of the patient if you can, and maybe even some additional information you gathered after the call was said and done. If you wish, you may display the call without the treatment or diagnosis to get an idea of how other paramedics would respond. I will start this off with my next post and hope it sparks some good discussion. PLEASE, no rude or useless comments. No judgemental side discussions.
FL_Medic Posted March 7, 2009 Author Posted March 7, 2009 My first call as a lone medic. BLS FD responded as well. Dispatch Notes: 25 y/o Male unresponsive. Breathing. Law enforcement on scene. Upon Arrival: 25 y/o male found sitting in recliner unresponsive with decreased respirations about 10/min. LE was on scene to arrest the indiviual for previous crime (grand theft). The patient was as is when they arrived. Unknown when the last time he was seen in a normal state. The patient was cool, pale, and diophoretic with dried emesis on his chest and around his mouth. An empty prescription bottle of Tramadol was found in a nearby bedroom. The patient failed to respond to verbal or painful stimuli. His initial blood pressure was 110/70 with a heart rate of 130. He was considered to be in compensatory shock. Opiate overdose was assumed due to his symptoms. No peripheral venous access was made after 2 failed attempts, and an external jugular vein was accessed. Narcan was chosen for administration to avoid having to intubate the patient (no back up medic on scene, hoping to just wake this dude up). Narcan was administered Slow IVP with a running line. The patient's respirations increased slightly and his O2 saturation improved (unsure of the actual percent). The patient began to display with abdominal contractions and the IVP was stopped. The patient presented with what appeared to be tremors, and was loaded up for transport. He did not regain consciousness, but frequently yawned in between "tremor episodes". In the Ambulance: just me back there Just as we left the residence the patient's oxygen saturation becan to drop with little increase in respiratory effort. His respirations decreased to about 8/min. BVM was applied to control the rate and depth with possitive increase in oxygentation. At this moment the patient began to decompensate and displayed with severe hypotension. A Dopamine infusion was set up in between ventilations and started. The patient continued to present with "tremors" and yawning. Arrival at the ED: ER RN states "Is he seizing?" ER Doc orders 10mg of Ativan This call opened my eyes. I don't know it all! The whole time the patient was displaying with tonic/clonic activity that the genius in me said was tremors. I researched Tramadol, learning that it has opiate properties but is considered a non-opiod analgesic. If Narcan is administered to this patient, seizures are a common side-effect. I learned that you can yawn while having a status episode. If I would have utilized our RSI protocol, the seizures wouldn't have been a problem, the airway would have been controlled, and I would have had a much easier time. Not to mention the obvious possibility of aspiration. Keep this in mind the next time you are treating a tramadol(Ultram) OD, learn from my huge mistake. They initially got the kids pressure up, and he suffered no perminant brain damage.
p3medic Posted March 7, 2009 Posted March 7, 2009 Well, playing Monday morning quarterback, I would disagree with the RSI and tx the sz with a benzo. RSI will help you control the airway, however paralyzing a patient just makes the motor activity of the sz go away, however the patient is still seizing. A benzo would be more appropriate, manage his airway with an adjunct and a BVM. If after you have controlled the seizure you feel the need to secure his airway, go ahead. I'm not suggesting ignoring a bad airway, but the vast majority of patient that are seizing don't require intubation. My Monday morning .02
FL_Medic Posted March 7, 2009 Author Posted March 7, 2009 Well, playing Monday morning quarterback, I would disagree with the RSI and tx the sz with a benzo. RSI will help you control the airway, however paralyzing a patient just makes the motor activity of the sz go away, however the patient is still seizing. A benzo would be more appropriate, manage his airway with an adjunct and a BVM. If after you have controlled the seizure you feel the need to secure his airway, go ahead. I'm not suggesting ignoring a bad airway, but the vast majority of patient that are seizing don't require intubation. My Monday morning .02 We give Etomidate in our RSI but that's beside the point. He wouldn't have siezed if I would have just RSI'd him. The Narcan made him sieze. Read all the way through the post agin. You're right, if he would have initially presented with seizures though. I am not a get-the-tube medic, I rarely find a need to intubate most patients. I have a few criteria that one must meet to be intubated and risk for aspiration is one of them.
AnthonyM83 Posted March 8, 2009 Posted March 8, 2009 Remember very little history, but remember being first on-scene to an elderly female babbling, trying to speak, and drooling profusely. Able to follow commands. Right after my ABC's, paramedics showed up and I presented her as having expressive aphasia. The report sounded good, so they let me do arm drift and push/pulls. She was a bit weaker on one side. Treated it as stroke. As soon as we roll into the ER, nurse says "She's having a seizure, guys!" It apparently it was a focal seizure only to her mouth. She did have one-sided weakness and the rest of my assessment was good...but I got narrowed into the expressive aphasia thing. Probably b/c I had a ride-along and got excited about showing him something he learned in class. Could tell the medic was disappointed...probably at himself for going with what I had said. :-/
mobey Posted March 8, 2009 Posted March 8, 2009 I dunno the details of this call so I am not gonna fake it, but here is the jist. Got called for a 26 y/o male possible OD. Pt found unconcious, shallow slow breathing. Narcan 0.4mg IV woke him up and he became aggressive. Pt transfered to rural hospital narcan witheld d/t agressive behaviour, resps watched closely. Rural hospital called for a transfer out to city hospital for ICU admit. City hospital calls rural hospital to ask the sending physician if the patient had ST elevation, + Troponin and > CK ........ OOPS..... guess someone shoulda done a 12 lead or/and drew blood
itxtme Posted March 8, 2009 Posted March 8, 2009 Mine was when I was 2nd or 3rd shift on the ambulance and we were sent to a big guy with abdo pain. The medic gave 5mg and 5mg of morphine justifying his big stature; this seemed to get on top of the pain. While were driving down to hospital the pt appeared to look a little pale so I took his BP 83/70; hmmm I said to myself must be too many bumps in the road so I hit it again. The pt flakes out and I call the medic in, I had no idea what was going on! Of course his BP caused the LOC and head down feet up sorted it out!! From this day on my first treatment for a decreased BP is positioning! I also believe that as a new medic you have to see some things at least once before you will fully recognize them in the field - to think how green I was
FL_Medic Posted March 8, 2009 Author Posted March 8, 2009 Remember very little history, but remember being first on-scene to an elderly female babbling, trying to speak, and drooling profusely. Able to follow commands. Right after my ABC's, paramedics showed up and I presented her as having expressive aphasia. The report sounded good, so they let me do arm drift and push/pulls. She was a bit weaker on one side. Treated it as stroke. As soon as we roll into the ER, nurse says "She's having a seizure, guys!" It apparently it was a focal seizure only to her mouth. She did have one-sided weakness and the rest of my assessment was good...but I got narrowed into the expressive aphasia thing. Probably b/c I had a ride-along and got excited about showing him something he learned in class. Could tell the medic was disappointed...probably at himself for going with what I had said. :-/ really wouldn't have changed your treatment. Focal seizures are commonly missed and rarely prehospital. I don't think you were completely wrong thinking this presentation was a CVA. Which is worse? Missing a stroke, or missing a focal sz? I dunno the details of this call so I am not gonna fake it, but here is the jist. Got called for a 26 y/o male possible OD. Pt found unconcious, shallow slow breathing. Narcan 0.4mg IV woke him up and he became aggressive. Pt transfered to rural hospital narcan witheld d/t agressive behaviour, resps watched closely. Rural hospital called for a transfer out to city hospital for ICU admit. City hospital calls rural hospital to ask the sending physician if the patient had ST elevation, + Troponin and > CK ........ OOPS..... guess someone shoulda done a 12 lead or/and drew blood 26 y/o, MI would be way in the back of my head. This is no where near as bad as mine! You guys are reaching. haha. Not bad though. Mine was when I was 2nd or 3rd shift on the ambulance and we were sent to a big guy with abdo pain. The medic gave 5mg and 5mg of morphine justifying his big stature; this seemed to get on top of the pain. While were driving down to hospital the pt appeared to look a little pale so I took his BP 83/70; hmmm I said to myself must be too many bumps in the road so I hit it again. The pt flakes out and I call the medic in, I had no idea what was going on! Of course his BP caused the LOC and head down feet up sorted it out!! From this day on my first treatment for a decreased BP is positioning! I also believe that as a new medic you have to see some things at least once before you will fully recognize them in the field - to think how green I was If MS was given the medic should have been in the back in the first place. BLS before ALS though, a good thing to remember. Positioning is huge. That's why syncope patient's wake up after the tumble, haha.
mobey Posted March 8, 2009 Posted March 8, 2009 No judgemental side discussions. This is no where near as bad as mine! You guys are reaching Drug use increases the risk of AMI at any age, this was a real eye opener for me as a medic student to ALWAYS thorouly assess my patients, no matter how clear cut the case may be. Although it was not a real "Holy $hit someone died because I missed a sign" call, it had a real impact on the type of medic I am becoming so I thought I would share in hopes it may help mold (mould) someone else.
Doczilla Posted March 8, 2009 Posted March 8, 2009 I recommend that we have a separate forum for this called "Morbidity and Mortality Conference" where each case can have its own thread. 'zilla
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