DwayneEMTP Posted May 28, 2012 Posted May 28, 2012 Actually, depending on the environment, I might choose to run this guy lights and sirens. It's early morning so in a smaller population it might not matter, but with a half hour transport I'm guessing that we're moving from rural to the city and at a time when the deer are starting to think about getting up and around. It may sound stupid, but I might run rural lights and sirens with this guy, best safe speed, just to keep the critters out of my way. I would also go ahead and set up another 2g of Mag to run in slowly. It 'appears' that we got a decent response to that, and either that or an increased O2 Sat has settled down his heart. I don't see the harm in it. I don't know how much fluid we ended up delivering but I'd run in another 250cc, assuming we're only at 250cc now and see how/if that effects his B/P and pulse rate. I'm going to guess that we'll see a decrease in both if we give him the right amount of fluid. But as we're not completely sure what's going on I don't want to commit until I see some more movement in a happy direction. It appears that we're on the right path now, but I always get a little bit worried when I'm pretty sure that I know why things are happening. So I want to keep moving in the same direction but verify at least every 5 minutes that we truly are moving in the right direction and not simply reacting to something unknown that's partially or completely responsible for this change instead. So, I'd push the steroids, 250cc bolus but let's run it in with another 2g Mag over 10-15 mins, let's recheck our SPO2 and ETCO2 and see if we note any significant changes, rerun a 12 lead if you can do that while moving, otherwise let's go ahead and set it up and have our partner pull over in a place where he can get immediately back underway, as his sats rise let's titrate to 95% (Not I'm not sure if this is a valid concern in this patient?? But let's do it anyway). I don't see any reason that I need anyone in back with me unless we have someone that can learn from patient care. We'll run lights and sirens at a quick/safe speed unless we see that the sirens are adding to our patients anxiety, then lights only, for the reason stated above. And head to the ER.
Bieber Posted May 28, 2012 Author Posted May 28, 2012 Dwayne, another great post. Mike, no foley, but good thoughts on it. Does anyone else have anything more to add before we conclude this scenario?
Kiwiology Posted May 28, 2012 Posted May 28, 2012 A pretty awesome scenario bro As far as managing him locally with no CPAP, magnesium or "in line" nebulisers that attach to a bag mask with an unwavering SPO2 of 87% on oxygen and 30 minutes to hospital he'd have bought a tube most likely.
DwayneEMTP Posted May 28, 2012 Posted May 28, 2012 Wait a second... This super progressive, better than all the rest system that you're constantly crowing about has no CPAP, Mag Sulfate or inline nebs? Huh..... 1
Bieber Posted May 28, 2012 Author Posted May 28, 2012 All right, folks, here's the epic conclusion to this scenario! First of all, thanks to everyone for participating. I hope you all enjoyed this scenario because I definitely did. Everyone had great ideas (including ones that my dumb ass didn't consider at the time) and I feel like getting your guys' input on this will definitely aid me in the future on similar calls. This was an actual patient, although I changed a few non-critical details just because. I was up for this call, although my partner rode in the back with me while driver drove us in emergency traffic because I triaged the patient code red (severe). The vitals and EKG were all true to this patient, and I was treating for what I thought was a COPD exacerbation due to infection--like a lot of you here did. I gave x1 albuterol treatments on scene and tried for an IV once before we moved the patient to the ambulance. My partner tried to get a line once en route but wasn't able to either, and I decided to start bagging in albuterol via BVM because unfortunately we don't have standing orders to use CPAP on COPD patients and I didn't realize that you could attach a nebulizer to them (thanks for teaching me something, Chris!). I didn't end up going with any epinephrine because of those episodes of tachycardia and the patient's elevated blood pressure, but my partner did give our patient a shot of methylprednisolone IM. By the way, I called those bouts of tachycardia V-tach, based on their similar morphology to the PVC's the patient was throwing and because I've never seen anybody go in and out of PSVT like that and I considered the rhythm most likely due to ventricular irritability secondary to the hypoxia. We bagged the patient with continuous albuterol all the way in and we managed to get their SpO2 up to 96% and their work of breathing significantly improved by the time we arrived at the hospital. I checked back later that night and found out that the patient had been admitted to the respiratory floor for an exacerbation of COPD secondary to pneumonia. I never did hear any crackles and while I briefly considered CHF, the overall presentation of the patient to me seemed to weigh more toward an acute COPD exacerbation than pulmonary edema. Now! Things I wish I had done differently: -IO: I was on the fence about starting an IO or not on this patient, and in the end I admit I honed in on just bagging the patient and pushing albuterol treatments down their throat. I also didn't consider it a priority at the time because I hadn't fully considered the next point... -Magnesium Sulfate: This we don't have by standing order but I could have called for, and I wish I had. I think I may have briefly considered it but for one reason or another didn't go back to the idea. I wish I had now, and maybe it would have helped turn the patient around quicker. -CPAP: Chris, I owe you for making me feel stupid about this one, and again for teaching me something. I really didn't think you could connect a nebulizer to CPAP (maybe because previously we've been so anti-CPAP for non-pulmonary respiratory disease), but now that I know, you can bet I'll be using this in the future. I still think that PPV via BVM was a good second best, but it definitely would have given me a chance to get more done if I hadn't been bagging the patient all the way in and it might have been more beneficial to them as well. -Fluid Bolus: I thought this was one of the best treatments suggested in this scenario, and one I would have definitely liked to have used if I had ever gotten IV or IO access. Kiwi, I know how you mentioned the tube, but to be honest I was there with Dwayne on this one. I wanted to avoid it at all costs, and even if I hadn't, we don't have RSI capabilities where I work and the patient remained conscious throughout transport. If it comes to it it comes to it, but given the DNR and the risk of secondary nosocomial infection, I felt like it was best avoided. I haven't followed up since the day I ran this patient to see if they made it out of the hospital or what, but it was one of the best calls I've had lately and I had a feeling you guys might enjoy it--and I hope you all did! I'm not used to employing mag or CPAP for these kinds of calls (due again to our protocols), but you guys have kind of made me realize I need to be making a better effort to think outside of the box and to call for orders if I don't have them by standing order and start utilizing these drugs and procedures that have been proven effective. So that's something I'm going to work on from now on. Thanks again to everyone who participated! Hopefully you all learned something from this scenario to, whether it's a new technique in respiratory management or maybe just a kick in the ass to get to using a technique you already knew but maybe haven't employed for whatever reason lately. 1
Kiwiology Posted May 28, 2012 Posted May 28, 2012 This super progressive, better than all the rest system that you're constantly crowing about has no CPAP, Mag Sulfate or inline nebs? No, funding is not at a level that allows them to be introduced to thousands of clinical people and hundred of response vehicles yet achieve a realistic cost/benefit ratio. The Ambulance Service has to compete with many other areas for the public health dollar. Something like CPAP is very expensive and only able to be used on a few patients; same with magnesium sulphate, while not as expensive it is only able to be used on a tiny subset of patients whereas two recent introductions on the other hand, oral ondansetron and oral loratadine, are extremely cheap and can be used on lots of patients. 1
DwayneEMTP Posted May 28, 2012 Posted May 28, 2012 I've been here a few days now and I can't think of 10 threads I'll bet that went so long that hadn't turned to shit after about the 25th post. I can't even begin to tell you how cool the participation was, but more so, how hard it is to run these scenarios without having them get all tangled up at some point. You should be really proud Biebs. I wasn't truly confident at any point but I had complete faith that if I walked down my treatment plan that I'd get the information that I needed to know if my path was a good one or not. Certainly one of the most excellent scenarios we've ever had. I hope that you'll do more. Did you find that presenting them is at least as good of a learning experience as participating in them?
chbare Posted May 28, 2012 Posted May 28, 2012 Agreed with everybody else. This was a sick scenario. No zebras, just a sick patient who required complex care and critical thinking. I'd definitely rank this as one of the best I've ever experienced here.
J306 Posted May 28, 2012 Posted May 28, 2012 This has been the first scenario I've been involved in so far with the city and I have to say I sure did learn a lot from it. That modification to add the nasal at 10-15lpm with a bvm/PEEP valve to create the same effect as CPAP was great. I'll be starting up ACP school in August and I'm going to really try and get involved in more scenarios and begin posting my own. I sure hope that there are more scenarios like this one in the future that we can all learn something from and challenge each other with. As for the rhythm, i've seen runs of both PSVT and V-tach in the field which both converted themselves back to NSR. I personally thought it resembled SVT but I may be mistaken. What do you guys think?
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