You look so good in mauve....

[hammerpcp]

Way to kill the scenario oh Google Master.

Let me read what you wrote very carefully.........Hmmmm.......okay I think I get the main point here: YOU DON"T KNOW! So STFU!

I am not about to start doing an exam which will ultimately not change my working diagnosis and definitely not my treatment of a pt........I wonder if you are even doing it correctly...Hmmm..... Also I have no need to demonstrate to everyone in the ER when I am giving my report that I have an exceptionally small penis and therefore must make up for it by pretending to know more then I do.

Using the pts bipap? Are you serious? And then WTF are we going to do Einstein? Hang out with his super cool winner of a brother, have a few Lakeports and smoke a pack of

Dunnhills while the fire boys figure it out?

And you are not tubing him because you don’t think it will survive the ride? Ever heard of tape? How good a seal do you think you can get with one person and the BVM on a face that looks like a deformed watermelon? I would be considering other factors in the big tube or not to tube decision....Like, how about is the tube going to make him worse? I don’t know about you but id rather breathe through a funnel then a straw any day. Or how about the fact that dude has a gag reflex? Vomit anyone? Or maybe even that we haven’t tried ANTYTHING yet!

Did anyone notice that this guy was PURPLE!!!!!????? And that he was sating at 73%??? And that he had NO AIR ENTRY???? Helloooooo!!!!!!!!!!!?????

How about some bronchodilators? How about some epinephrine even?

Come on people. Like I said I ain't no brain scientist, but I sure as hell know that this Pt is not hypoxic and damn near dead from a sugar overdose and a nasal cannula at 2lpm.

OH the humanity!

8)

[fiznat]

Whatever dude, I'm not here to prove anything to you. You said you didn't know what it was so I told you as much as I know. I am a paramedic, not a neurologist, and while I cannot trace the pathology of plantar reflex for you to it's minituae, I can tell you without a doubt that it is a valuable finding, and an easy test to do, for any potentially neuro-compromised patient. If you don't feel it is necessary, and would rather not read about it, then honestly I really could give a shit.

Every medic here, though, should know what a freaking extrapyramidal (AKA dystonic) reaction is. The fact that you confused this (with two names specifically excluding one from another!) doesn't bode well at all.

Perhaps if you presented your "case study" (if that is even what this is) in a more organized and professional manner, you would get a few more serious supplies. When you openly mock a patient for his weight, then admit that you didn't even bring in any of your gear to the call, your credibility tends to slide down a few notches. Using childish name calling and references to penis size in response to a legitimate reply to your thread doesn't help either. Get over yourself.

[hammerpcp]

Whatever dude, I'm not here to prove anything to you. You said you didn't know what it was so I told you as much as I know.

You told me what you found in a wikipedia search. I often find myself waiting with bated breath for someone to regurgitate Wikipedia’s often mis-information to me. Oh wait. I can read for myself.

I am a paramedic, not a neurologist, and while I cannot trace the pathology of plantar reflex for you to it's minituae, I can tell you without a doubt that it is a valuable finding,

How do you know it’s a valuable finding? You don’t even know what it means!

and an easy test to do, for any potentially neuro-compromised patient. If you don't feel it is necessary, and would rather not read about it, then honestly I really could give a shit.

In fact I find the Babinski reflex very interesting. The real problem here is that I don’t want to hear about it from you. This is because you admittedly are doing an assessment – perhaps incorrectly as well?- that you don’t understand, that has no bearing on your treatment or working diagnoses of the pt. I can only presume that you are motivated to do this assessment by the potential little ego stroking you may receive when giving report. When you, or anyone pretends to know more then they do, they look ridiculous and are pretending to be something they are not. Those who need their egos stroked, especially when it is not merited, are frequently insecure about certain personal attributes.

Every medic here, though, should know what a freaking extrapyramidal (AKA dystonic) reaction is. The fact that you confused this (with two names specifically excluding one from another!) doesn't bode well at all.

By the power of Google thou art now the expert? You are really being ridiculous. You clearly demonstrated in this scenario at what level you are performing and that is poorly at best. For a working paramedic to be focusing on neurological symptoms (that he doesn’t understand… ….but we’ve been over that) on a pt that is in near respiratory failure prior to securing an airway, breathing or any treatment interventions is laughable. And now you play the scholar; The person pointing fingers at others for lacking knowledge in a certain area, when you have just failed at performing even the most basic of life saving interventions.

Perhaps if you presented your "case study" (if that is even what this is) in a more organized and professional manner, you would get a few more serious supplies. When you openly mock a patient for his weight, then admit that you didn't even bring in any of your gear to the call, your credibility tends to slide down a few notches. Using childish name calling and references to penis size in response to a legitimate reply to your thread doesn't help either. Get over yourself.

Get off your high horse. Are you even a paramedic? You are in no position to make any judgments about anyone’s creditability at this point. The fact of the matter is that you had no problem with participating in this scenario and thus any slights you make about it now can only be interpreted as you being resentful. In addition your treatment/interventions were poorly prioritized at best, and completely incompetent at worst. On top of that, you are a phony trying to take credit for, and not only that but put others down! For information you don’t even hold yourself!!!

8)

[spenac]

Crap another good post has become a bash fest. I did not do it this time.

[ccmedoc]

I think you are confusing the pyramidal tract with extrapyramidal response

The pyramidal motor tract, more correctly a "system" primarily involved in mediating voluntary muscle response...

There is also an extrapyramidal system of nerve fibers primarily responsible for involuntary motor excitation....

Fiznat, you are on the right track with the dystonic symptoms BUT, I fail to see what either of these do with the scenario. I would think to argue with the original poster, Mr. hammerpcp, would prove to be an excercise in futility. In his postings he would appear to have little to no respect for anyone other than himself, with all the namecalling and such..

Such eloquent verbage... :roll:

verbage /ver'b*j/ n. A deliberate misspelling and mispronunciation of

verbiage that assimilates it to the word `garbage'.

Fiznat, thumbs up for trying to throw in a bit of education into the mix.....Appearantly some are in it more for the argument than for the solution. Not at all worth the effort, but absolutely amusing.

[fiznat]

Sigh.

The reason we check for neurological signs in an unconscious patient is to rule out factors that may be contributing to the entire presentation. Ever heard of an overdose? How about respiratory insufficiency secondary to any other pathology? (hint: this happens a lot). To find fault in the fact that I did not treat and assess airway issues before asking about neurological function on an internet posting board is pretty silly. OBVIOUSLY you deal with these things first. This is the ALS forum. Would you like me to walk you through positioning of the airway, inserting basic adjuncts, and ventilating? How about we go over how to plug the oxygen tubing to the D tank? BLS comes before ALS, of course, but get a grip. We assess, then treat.

A full neurological exam, or at least a rapid field exam, would be absolutely appropriate in this case. Do we know if this patient is unconscious because he his hypoxic or hypoxic because he is unconscious? Obese patients have big problems maintaining their airways (and diaphragmatic pressures) when they are conscious and able to optimally position themselves, so imagine those issues compounded in someone who is unconscious. You say you could not hear lung sounds. Is this because of his size or because there is a pulmonary issue? How come he couldn't have stroked out and slumped himself into hypoxia? Why not a sugar problem, an overdose, a seizure, trauma, or cardiac? You seem to be ready to load this patient up with bronchodilators and epinephrine, and you haven't even done a complete assessment! Excuse me for my interest in being a little bit more thorough before we start throwing drugs around.

To argue that I "don't understand" what plantar reflex means is tantamount to me saying that you might as well not check pupil response, or do a Cincinnati stroke scale because I doubt you could adequately detail the exact pathologies involved there, either. Can you tell me the cellular reactions that give nitro it's vasodilatory effect? Can you explain to anyone in true detail how adenosine causes it's nodal blocking? No, you cant. The reason you perform these tests, and the reason you give these drugs, is because someone who knows more than you told you that you should. You and I are paramedics, not doctors or medical scientists on any level. To say that I am not a good paramedic (or even a paramedic at all??) because my knowledge does not reach to the infinite details of cellular and neurological minituae is absolutely preposterous.

It seems you would rather argue then talk about this patient anyways, so please feel free.

*In response to other posters: I only brought up dystonic reaction because it seems the OP had confused it with something else. Although I admit we thus far know very little about this patient, I don't think any of us would think that this is a dystonic reaction. I referenced the pyramidal tract (or system?) because I believe this is typically one of the areas responsible for a pathological Babinski reflex.

[hammerpcp]

Fiznat, you are on the right track with the dystonic symptoms BUT, I fail to see what either of these do with the scenario. I would think to argue with the original poster, Mr. hammerpcp, would prove to be an excercise in futility. In his postings he would appear to have little to no respect for anyone other than himself, with all the namecalling and such..

Such eloquent verbage... :roll:

Blah blah blah.

Fiznat, thumbs up for trying to throw in a bit of education into the mix.....Appearantly some are in it more for the argument than for the solution. Not at all worth the effort, but absolutely amusing.

You speak of education? That was the entire goal of the original post. You are completely mistaken about my motives. Fiznat is a big boy I am sure he is capable of defending himself without a cheerleading squad.

Whether to intubate a Pt experiencing an exacerbation of a reactive airway disease is a very real and current debate. One that I was interested in getting the views of my colleagues on. Needless to say, I was immensely disappointed at the response. Not only the weak responses that were received - we all started somewhere and I fault no one for asking questions or suggesting long shots, although I may find it humorous - however, I do have a problem with people trying to misrepresent their own knowledge and trying to make others look less capable under false pretenses.

Another very pertinent debate that may have arose form this scenario is whether or not to administer epinephrine to this pt. Whether the benefits outweigh the risks.

In the prehospital setting, in my service this is a touchy debate because obviously we do not have access to all the medications that they do in the ER. For example, we can not administer MDI medication to a pt who is not intubated, but in order to administer a nebulized bronchodilator one would have to stop bagging this pt. So what do you do?

Also, we do not have the capacity for RSI, so the question is even if you CAN intubate this pt, due to his large size and copious amounts of soft tissue, will topical lidocaine alone be enough to dampen his gag reflex? And then can we sedate him post intubation, or will that create too many other systemic complications i.e. a further drop in BP, etc.

Then there is the concern that intubated COPD pts often end up having a poorer outcome then non-intubated pts so the alternative of BiPap is often a good one but again unfortunately not an option for us prehospitally. BUT can this pt afford to be hypoxic for another five, ten or fifteen minutes while we extricate him and give him nebulization treatments and/or suction the secretions from his airway?

So, as you can see this could be a very interesting, educational and pertinent discussion about topics that we CAN understand, and CAN make a difference about.

As far as respect goes, make no assumptions of MR Hammerpcp. Let me explain SOP to you: In general a base line of respect is forwarded to every individual, call it the benefit of the doubt. But then it is up to the other person to either foster and nurture that respect……being honest and having integrity, not misrepresenting themselves or being hypocritical……or to lose that respect by doing the opposite. You do the same no doubt.

Sigh.

The reason we check for neurological signs in an unconscious patient is to rule out factors that may be contributing to the entire presentation. Ever heard of an overdose? How about respiratory insufficiency secondary to any other pathology? (hint: this happens a lot). To find fault in the fact that I did not treat and assess airway issues before asking about neurological function on an internet posting board is pretty silly. OBVIOUSLY you deal with these things first. This is the ALS forum. Would you like me to walk you through positioning of the airway, inserting basic adjuncts, and ventilating? How about we go over how to plug the oxygen tubing to the D tank? BLS comes before ALS, of course, but get a grip. We assess, then treat.

I am not faulting you for doing a full assessment. I am faulting you for that being your priority when it shouldn’t be. Assessments are done in a certain order of life sustaining priority because if we find a problem during one of our assessments….for example airway……we intervene. We treat immediately and continue the rest of the assessment later if possible. This means that in situations like the one posted, we would assess the pts airway and breathing (as of course you know more then one assessment can often be made at a time hence the importance of ‘the look test’) recognize there is a problem and treat it immediately.

A full neurological exam, or at least a rapid field exam, would be absolutely appropriate in this case. Do we know if this patient is unconscious because he his hypoxic or hypoxic because he is unconscious? Obese patients have big problems maintaining their airways (and diaphragmatic pressures) when they are conscious and able to optimally position themselves, so imagine those issues compounded in someone who is unconscious. You say you could not hear lung sounds. Is this because of his size or because there is a pulmonary issue?

That is the smartest thing I have heard you say in days! So which do you think it is with this pt? With the tools at hand (SpO2 sensor and your senses) how would you proceed with treatment?

How come he couldn't have stroked out and slumped himself into hypoxia? Why not a sugar problem, an overdose, a seizure, trauma, or cardiac? You seem to be ready to load this patient up with bronchodilators and epinephrine, and you haven't even done a complete assessment! Excuse me for my interest in being a little bit more thorough before we start throwing drugs around.

You know this is a brilliant post. I think you may have swayed my opinion of you although I still suspect you of having some misplaced and possibly unmerited arrogance. I did do a thorough assessment on this pt in ‘real life’ and came to the conclusions that I did (I did omit the planter flexion vs. extension assessment ) and treated accordingly. There were many other options in how to manage this pt in retrospect, hence the post. To gather the opinions and ideas of others. Preferably competent others.

To argue that I "don't understand" what plantar reflex means is tantamount to me saying that you might as well not check pupil response, or do a Cincinnati stroke scale because I doubt you could adequately detail the exact pathologies involved there, either. Can you tell me the cellular reactions that give nitro it's vasodilatory effect? Can you explain to anyone in true detail how adenosine causes it's nodal blocking? No, you cant. The reason you perform these tests, and the reason you give these drugs, is because someone who knows more than you told you that you should. You and I are paramedics, not doctors or medical scientists on any level. To say that I am not a good paramedic (or even a paramedic at all??) because my knowledge does not reach to the infinite details of cellular and neurological minituae is absolutely preposterous.

Actually I do have a certain level of understanding of all the assessments that I do and what the findings mean. Understanding at a cellular level especially with pharmaceuticals is not only irrelevant (in a ‘need-to-know’ kind of way) but often impossible since the “exact mechanism of action is not fully understood” more frequently then not. You won’t catch me assessing for heart sounds in a more in depth way then that they are present or not either. This is because the different sounds mean nothing to me. I may hear an abnormality but will that change my treatment? Will I even be able to identify what is causing the abnormality? No. so I don’t check. I don’t do assessments simply because someone told me I should. If I am unable to interpret the results of the assessment, which can be very nuanced (is it a KEN-TUCK-Y or a Ten-nes-see? ) and therefore the assessment has to be repeated anyway by someone who can interpret the findings, what is the point?

I think I am seeing the problem now. Maybe this is a fundamental issue; meaning that your system and training is set up differently then mine at the most basic level. You have the approach of a technician in that ‘if you find such and such symptom you do so and so’. Whereas we are trained more as clinicians in that ‘if you find such and such a sign it could indicate so and so or this and this and therefore you should try that and that to correct the problem’. Clear as mud? Inevitably of course there is over lap between the two approaches, neither is completely pure.

I am giving you the benefit of the doubt now. It is possible that I misinterpreted your doing assessments you don’t fully understand as an attempt to make yourself out to be something that you aren’t; someone more skilled and knowledgeable then you are. And of course the only motivation a person has for doing this is because their penis is small.

In actuality it seems that this is not your situation. That perhaps you do not have a small penis or at least you are not concerned enough about it to try and compensate (are you smiling yet?) for it. But that you are simply doing what “someone who knows more than you told you that you should”.

It seems you would rather argue then talk about this patient anyways, so please feel free.

I hope you realize that this is not the case.

8)

[fiznat]

Consider this: your thread has been posed in the ALS forum for 5 days, and viewed just shy of 500 times by our members. In that time, not a single person has started to go down the path of reactive airway for this patient. I ask you to consider that perhaps this has more to do with the way the scenario was presented rather than some insufficiency on behalf of your readers.

You are right that questions whether to intubate asthma patients, when to give epinephrine, etc are valid and interesting ones - IF we are certain that our patient is experiencing reactive airway. Thus far, I don't think many of us have been convinced of this. While it may have been obvious "in real life," as you say, it is not so clear here. THAT is why I asked for a more thorough neurological survey than you seem to have expected, because as far as I know: this patient is unconscious (or severely altered), and that alone may be the source of his pathology. It is worth a look.

As far as doing airway stuff first, again, give me a break. You already said that a basic adjunct was placed, that the patient was being ventilated, and positioning had been changed. All of this, you said, lead to some color change and an increasing mental status. SPO2 came up to just shy of 90%. I don't see why BLS management of this airway wouldn't be fine until a more thorough ALS assessment is performed. ...And even still, this basic stuff should almost be assumed at this level. If we want to talk about drugs and intubation, let's give eachother the benefit of the doubt that we are able to comprehend basic airway management. You mentioned a "baseline level of respect?"

As far as my understanding of the Babinski reflex, I believe I understand it well enough for the evaluation to be valid. I learned in school (not a google search, as you so rudely accused) that a positive Babinski test in patients over 2 years old indicates significant upper motor neurological damage which often carries with it a very poor prognosis. I remembered vaguely that often it was a structure called the pyramidal tracts (or system, as others have corrected) that was the source of the damage, but I admit I was not quite sure where the pyramidal tracts were or exactly what function (outside of motor control, obviously) they performed. I did do a quick search to validate that information, which I believe is reasonable. I in no way tried to pass this knowledge off on my own, in fact I TOLD you what came from Wikipedia-- this is how you know I got it there! I would hardly consider this arrogance, and - considering our depth of knowledge on many other subjects - I think my level of understanding on this subject is sufficient enough to perform this valuable exam. You mentioned that some shortcomings in knowledge are acceptable "in a 'need to know' kind of way." I propose that knowledge of the exact Babinksi pathology is not necessary for the test to be valuable in the field. It is not nuanced, as heart sounds can be, it is simple, easy, quick, and indicative of neurological damage that may otherwise lay hidden. It may not abruptly change our treatment modality, but it is part of a complete picture, and I think there is value in that other than simply trying to impress others. Perhaps our training is not as different as you say.

Anyways, maybe we can get back to the scenario.

we can not administer MDI medication to a pt who is not intubated, but in order to administer a nebulized bronchodilator one would have to stop bagging this pt. So what do you do?

Again, assuming this is indeed reactive airway, why cant you administer nebulised meds to a patient who is not intubated? Is this written in your protocol somewhere? You don't have to stop bagging a patient to administer a treatment, either. It is a bit of a funky setup, but a BVM and nebuliser chamber can be attached together in a way so that you bag in a treatment. I have done this before, and it works really well.

[hammerpcp]

I am considering............Nah. I don’t think that it has been shown that the scenario was misunderstood. It went awry too early on. No one else has demonstrated any opinion one way or another about what they suspect is happening with this pt.

I don’t think it's so preposterous for someone presented with even the absolute basics of this case to come to a pretty probable conclusion on the pts condition. Basic facts initially presented being that the pt is severely hypoxic, demonstrated by colour and decreased LOC and he has a respiratory hx- most likely late stage COPD- illustrated by the presence of home O2. With this information alone it would be fair for anyone to jump immediately to airway management and ventilatory treatment. Even if the pts primary problem was not respiratory in origin.....no breathy no livey, and so we take care of this first. How can you disagree?

As far as taking care of the basics first goes, I can not assume anything of anyone on this forum. I don't know what the training or skill level of the people who are responding to the post is. It would be inappropriate to assume they are anything more then EMT-b's looking for a little brain teaser. The average level of knowledge on this board is often on the low end of the scale - don’t get me wrong I have nothing but praise for those who seek knowledge- but the fact remains that basic interventions don't go without saying. Since I don't know you this also applies to you. Just because this is a post made in the ALS forum doesn't mean that only ALS trained individuals can and will answer.

How rude of me to say Google when you clearly went straight to Wikipedia. How dare I? Babinski schmaminski. Do whatever assessments you want whether they are valid or not. If "someone who knows more then you do told you to" is enough reason for you then go ahead. I am still not entirely convinced that you aren’t motivated by a need to impress people but I am still giving you the benefit of the doubt. And I am sure what I think is utterly irrelevant to you. But I digress........

Anyways, maybe we can get back to the scenario.

Praise the Lord!

="fiznat"]

Again, assuming this is indeed reactive airway, why cant you administer nebulised meds to a patient who is not intubated? Is this written in your protocol somewhere? You don't have to stop bagging a patient to administer a treatment, either. It is a bit of a funky setup, but a BVM and nebuliser chamber can be attached together in a way so that you bag in a treatment. I have done this before, and it works really well.

Please express your ideas. If you don't think it is reactive airways what do you think the problem is? I believe I have answered all your questions about pt presentation. Do you need more information?

I have never seen what you describe being done and I don't believe that it would be considered kosher by my BH however I am interested none the less. Improvisation is the name of the game.

[rock_shoes]

Ok. Ignoring the banter between some of the members I do have a couple of questions. I'm not ALS at this point and responded to this post more as a learning exercise than anything.

First of all Hammer (bear in mind I'm not familiar with local protocols). Would it not have been possible to use a dose of epinephrine to open up the airway enough to use a ventolin MDI without intubating? If it's outside of your scope enough said. I'm not looking for a debate on what protocols should be allowed. Second. Is RSI not allowed in ontario at all or is it limited to a select group of medics.