# You respond to 40 y/o with chest pains and coughing



## jhall98 (Oct 17, 2015)

respiration 24.. oxygen saturation is 85%, bp 100/75 chest rise and fall is diminished on left side of chest, c/c is coughing up blood.. hes having a hard time breathing.. Your partner then goes into sudden cardiac arrest and you two are the only ones on scene.. Mind you I am a student so im still kind of a newbie at this.


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## chaz90 (Oct 17, 2015)

What are you looking for here? Triage priority? This sounds like a mass casualty drill, but a ridiculous realistic scenario.


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## Ewok Jerky (Oct 17, 2015)

BSI/ scene safety


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## jhall98 (Oct 17, 2015)

Yeah pretty much.. Would you treat your partner first? And what if there were no other units available.. in a very rare scenario


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## Ewok Jerky (Oct 17, 2015)

Seriously?


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## jhall98 (Oct 17, 2015)

yeah just think about it.. The guy is going into hypovolemic shock.. Its a rural area and theres only 2 crews you and another.. Hes lost so much blood from coughing up so much and your partner is in cardiac arrest.. what do you do?


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## jhall98 (Oct 17, 2015)

Ill make it a little more simpler.. If you are out on a call.. and something happens to your partner.. no help whatsoever.. and you have a patient.. Do you transport them both? Its one of my biggest questions ive had


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## DesertMedic66 (Oct 17, 2015)




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## DesertMedic66 (Oct 17, 2015)

jhall98 said:


> Ill make it a little more simpler.. If you are out on a call.. and something happens to your partner.. no help whatsoever.. and you have a patient.. Do you transport them both? Its one of my biggest questions ive had


You're not even going to be able to transport one of them. Who is going to drive if your partner is down? If you drive then who is going to do patient care? I like Casper and all but he has never been much help on any of my calls.


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## jhall98 (Oct 17, 2015)

Lol


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## RedAirplane (Oct 17, 2015)

Strict triage says black tag your partner. However, he's probably viable. 

I would ask for any help I can get. You can't go anywhere so work the arrest and wait for another ambulance even if it's coming from afar. 

If you have more than two arms, get your original patient on oxygen. What else can you do for him?


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## RedAirplane (Oct 17, 2015)

chaz90 said:


> What are you looking for here? Triage priority? This sounds like a mass casualty drill, but a ridiculous realistic scenario.



It's absolutely ridiculous but something I've wondered about.


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## BOS 101 (Oct 17, 2015)

Playing along with the bs of that scenario, Idk about legal things, but IMO you have 2 patients
Not an MCI so you can't black tag anyone, call for backup (hell ask a pedestrian if they can do compressions 4 u) and use time that you aren't shocking or bagging pt 2 (maybe just hands only no bagging if necessary) to put #1 into motion
what you think?


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## LACoGurneyjockey (Oct 17, 2015)

Leave the keys in the ignition and start walking home


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## Jim37F (Oct 17, 2015)

Hopefully you've already put the original patient on a non rebreather or CPAP (depending on severity of their SOB and local protocols). In that case, call for help, at least one, if not two additional ambulances plus PD and FD assistance and work on chest compressions until the cavalry arrives.


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## Jim37F (Oct 17, 2015)

BOS 101 said:


> Playing along with the bs of that scenario, Idk about legal things, but IMO you have 2 patients
> Not an MCI so you can't black tag anyone, call for backup (hell ask a pedestrian if they can do compressions 4 u) and use time that you aren't shocking or bagging pt 2 (maybe just hands only no bagging if necessary) to put #1 into motion
> what you think?


In my area an MCI isn't defined by a specific number of patients but instead where the initial first response is overwhelmed which I'd say the lone EMT is most certainly overwhelmed at this point. Not that I'd personally pull that trigger in this case (we always have an engine company auto dispatched to all medical with us plus being in an urban area I can have lots of resources in a few minutes with a single radio call)


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## Gurby (Oct 18, 2015)

Guy with SOB coughing up blood, partner just went into cardiac arrest for no apparent reason... My first thought is that there is some sort of airborne chemical or something, and I need to get out right now.  Screw the patient, I'm dragging my partner's body out of the area if possible (and certainly not going back in for the patient...), calling for additional resources and notifying of potential hazmat situation, then CPR/defib on my partner.



Jim37F said:


> Hopefully you've already put the original patient on a non rebreather or CPAP (depending on severity of their SOB and local protocols). In that case, call for help, at least one, if not two additional ambulances plus PD and FD assistance and work on chest compressions until the cavalry arrives.



I don't feel so good about CPAP given "chest rise and fall diminished on left side of chest" and "c/c is coughing up blood".  If he's got a pneumothorax, CPAP is going to finish him off pretty quickly.  Also if there is a lot of blood in the mouth/oropharynx you could cause some problems.


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## Gurby (Oct 18, 2015)

jhall98 said:


> Ill make it a little more simpler.. If you are out on a call.. and something happens to your partner.. no help whatsoever.. and you have a patient.. Do you transport them both? Its one of my biggest questions ive had



Depends on the situation, but realistically 90% of the time you're probably going to want to wait on scene.  Call for 2 more ambulances, do whatever you can on scene for both patients, wait for other crews to come pick up your partner and the patient.  This could theoretically change if you were in an extremely rural area, if one or both of the patients had some time-critical problem, etc.


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## Ewok Jerky (Oct 18, 2015)

Ok guys, but what if your radio battery was dead and the oxygen cylander had a leak and was empty too. Then what?!?!?


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## jhall98 (Oct 18, 2015)

Gurby said:


> Guy with SOB coughing up blood, partner just went into cardiac arrest for no apparent reason... My first thought is that there is some sort of airborne chemical or something, and I need to get out right now.  Screw the patient, I'm dragging my partner's body out of the area if possible (and certainly not going back in for the patient...), calling for additional resources and notifying of potential hazmat situation, then CPR/defib on my partner.
> 
> 
> 
> I don't feel so good about CPAP given "chest rise and fall diminished on left side of chest" and "c/c is coughing up blood".  If he's got a pneumothorax, CPAP is going to finish him off pretty quickly.  Also if there is a lot of blood in the mouth/oropharynx you could cause some problems.



wow nice one


Ewok Jerky said:


> Ok guys, but what if your radio battery was dead and the oxygen cylander had a leak and was empty too. Then what?!?!?


and your ambulance battery is dead and no gas in it. tires are flat and your defib is broken.


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## NomadicMedic (Oct 18, 2015)

jhall98 said:


> and your ambulance battery is dead and no gas in it. tires are flat and your defib is broken.



...and there are zombies in the woods and they smell brains and you don't have anything on you to kill no zombies and meanwhile that freakin' guy is still coughing up blood and your partner is still dead...


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## Flying (Oct 18, 2015)

...and your partner then rises as a new zombie and tries to eat you and the crews coming in to assist you are overwhelmed as well.


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## teedubbyaw (Oct 18, 2015)

Depends on how much I like my partner. If it's Chewy, then no go. If it's Stxmedic, then I may help him.


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## RedAirplane (Oct 18, 2015)

DEmedic said:


> ...and there are zombies in the woods and they smell brains and you don't have anything on you to kill no zombies and meanwhile that freakin' guy is still coughing up blood and your partner is still dead...



Ask all zombies that are able to walk to proceed to the yard and green tag themselves.


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## BOS 101 (Oct 18, 2015)

DEmedic said:


> ...and there are zombies in the woods and they smell brains and you don't have anything on you to kill no zombies and meanwhile that freakin' guy is still coughing up blood and your partner is still dead...


 
Suddenly I'm starting to like this sim...


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## BOS 101 (Oct 18, 2015)

Jim37F said:


> In my area an MCI isn't defined by a specific number of patients but instead where the initial first response is overwhelmed which I'd say the lone EMT is most certainly overwhelmed at this point. Not that I'd personally pull that trigger in this case (we always have an engine company auto dispatched to all medical with us plus being in an urban area I can have lots of resources in a few minutes with a single radio call)


 Hm that's interesting never thought of that or heard of a system like that


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## RedAirplane (Oct 19, 2015)

BOS 101 said:


> Hm that's interesting never thought of that or heard of a system like that



I believe the trend is towards defining MCI in terms of being overwhelmed. Most things I have read have stated that the definition is purposefully ambiguous.


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## Ewok Jerky (Oct 19, 2015)

BOS 101 said:


> Hm that's interesting never thought of that or heard of a system like that


It's just smart triage and a provider realizing they are are overwhelmed.


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## Tigger (Oct 25, 2015)

Putting numbers on MCI declarations are silly. There is no way to predict what resources will quickly be available to you, if any. If you can't handle it, it's an MCI until you have what you need.


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## Martyn (Oct 26, 2015)

jhall98 said:


> yeah just think about it.. The guy is going into hypovolemic shock.. Its a rural area and theres only 2 crews you and another.. Hes lost so much blood from coughing up so much and your partner is in cardiac arrest.. what do you do?



Go sit in the corner and suck my thumb and cry for my mummy


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## DesertMedic66 (Oct 26, 2015)

Martyn said:


> Go sit in the corner and suck my thumb and cry for my mummy


I do that for the majority of my calls


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## Seirende (Nov 1, 2015)

How is it that serious threads end up being funnier than most of the humor threads?


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## NYBLS (Nov 4, 2015)

We really need to answer some other question before we can make a determination:

1) Do we like our partner?
2) Is his life insurance paid up?
3) How hot is his wife?


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## SixEightWhiskey (Nov 5, 2015)

Another important question: are you upset at your partner for ostracizing you for coming up with outlandish scenarios that involve his death?


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## jhall98 (Nov 15, 2015)

NYBLS said:


> We really need to answer some other question before we can make a determination:
> 
> 1) Do we like our partner?
> 2) Is his life insurance paid up?
> 3) How hot is his wife?


his wife is a 4 out of 10. No life insurance and your boss loves your partner tons more than you.


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## Qulevrius (Nov 28, 2015)

jhall98 said:


> his wife is a 4 out of 10. No life insurance and your boss loves your partner tons more than you.



Acquire both partner's wife & boss, throw them in the back of the rig with your turned partner, put on Disco Inferno, sit back, grab some popcorn & enjoy the show.


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## iExposeDeformities (Nov 27, 2017)

jhall98 said:


> respiration 24.. oxygen saturation is 85%, bp 100/75 chest rise and fall is diminished on left side of chest, c/c is coughing up blood.. hes having a hard time breathing.. Your partner then goes into sudden cardiac arrest and you two are the only ones on scene.. Mind you I am a student so im still kind of a newbie at this.


So we have a patient with suspected hemothorax and a partner that suddenly went into cardiac arrest.....run?


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## luke_31 (Nov 27, 2017)

iExposeDeformities said:


> So we have a patient with suspected hemothorax and a partner that suddenly went into cardiac arrest.....run?


Only a two year resurrection, but yeah it's a definite run.


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## VFlutter (Nov 28, 2017)

iExposeDeformities said:


> So we have a patient with suspected hemothorax and a partner that suddenly went into cardiac arrest.....run?



A lot of reasons for Hemoptysis other than Hemothorax and probably more likely.


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## iExposeDeformities (Nov 29, 2017)

Chase said:


> A lot of reasons for Hemoptysis other than Hemothorax and probably more likely.


The part that highlighted to me that it was hemothorax was the “chest rise and fall diminished on left side” but after reading it again “coughing up blood” it could in fact be hemoptysis since hemothorax technically means blood in the pleural space


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## Qulevrius (Nov 29, 2017)

iExposeDeformities said:


> The part that highlighted to me that it was hemothorax was the “chest rise and fall diminished on left side” but after reading it again “coughing up blood” it could in fact be hemoptysis since hemothorax technically means blood in the pleural space



Hemo and pneumo do not present the same. Diminished/absent unilateral chest fall and rise is characteristic of tension pneumo, not hemo. Other s&s apply, including abnormal percussion, trach deviation etc. And hemoptysis, by definition, _is_ coughing up blood.


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## Tigger (Nov 30, 2017)

Qulevrius said:


> Hemo and pneumo do not present the same. Diminished/absent unilateral chest fall and rise is characteristic of tension pneumo, not hemo. Other s&s apply, including abnormal percussion, trach deviation etc. And hemoptysis, by definition, _is_ coughing up blood.


Well, until it's a hemopneumothorax...


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## Qulevrius (Nov 30, 2017)

Tigger said:


> Well, until it's a hemopneumothorax...



...which will present as a pneumo plus abnormal SS & hypotension. I’m still voting for Disco Inferno and popcorn


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## iExposeDeformities (Dec 1, 2017)

Qulevrius said:


> Hemo and pneumo do not present the same. Diminished/absent unilateral chest fall and rise is characteristic of tension pneumo, not hemo. Other s&s apply, including abnormal percussion, trach deviation etc. And hemoptysis, by definition, _is_ coughing up blood.


So you’re telling me that if large volumes of blood fill into the pleural space thereby preventing the lungs from expanding as much as they should, chest rise and fall will be bilaterally equal/normal?


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## Qulevrius (Dec 1, 2017)

iExposeDeformities said:


> So you’re telling me that if large volumes of blood fill into the pleural space thereby preventing the lungs from expanding as much as they should, chest rise and fall will be bilaterally equal/normal?



What I’m saying is that you should consider brushing up on your understanding of clinical presentations. Starting with going back to, and rereading, the OP.


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## iExposeDeformities (Dec 1, 2017)

Qulevrius said:


> What I’m saying is that you should consider brushing up on your understanding of clinical presentations. Starting with going back to, and rereading, the OP.


I know hemo and pneumo do not present entirely the same. What I am saying though is unequal chest rise is also a presentation of hemothorax. If you don’t realize why maybe I’m not the one who needs to “brush up”


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## Qulevrius (Dec 1, 2017)

iExposeDeformities said:


> I know hemo and pneumo do not present entirely the same. What I am saying though is unequal chest rise is also a presentation of hemothorax. If you don’t realize why maybe I’m not the one who needs to “brush up”



Why won’t you enlighten us and explain the physiological reasons for having an asymmetrical chest rise/fall.


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## iExposeDeformities (Dec 1, 2017)

Qulevrius said:


> Why won’t you enlighten us and explain the physiological reasons for having an asymmetrical chest rise/fall.


Blood fills into pleura and limits lung expansion. Both blood and air will take up pleural space which is why both pneumo and hemo have unequal chest rise and fall


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## iExposeDeformities (Dec 1, 2017)

Qulevrius said:


> Why won’t you enlighten us and explain the physiological reasons for having an asymmetrical chest rise/fall.


https://www.scribd.com/mobile/doc/36892389/Pathophysiology-Hemothorax


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## Qulevrius (Dec 1, 2017)

iExposeDeformities said:


> Blood fills into pleura and limits lung expansion. Both blood and air will take up pleural space which is why both pneumo and hemo have unequal chest rise and fall



So per scenario, you have a tachypneac, desatting pt with diminished unilateral chest movement, hemoptysis & OK’sh bp, and that cues you in on hemothorax ?

The part about my question that went 20 ft over your head was ‘why is it happening’, not ‘what’s the outcome’.


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## iExposeDeformities (Dec 1, 2017)

Qulevrius said:


> So per scenario, you have a tachypneac, desatting pt with diminished unilateral chest movement, hemoptysis & OK’sh bp, and that cues you in on hemothorax ?
> 
> The part about my question that went 20 ft over your head was ‘why is it happening’, not ‘what’s the outcome’.


100/76 would be considered ok depending on the pulse which we don’t have. If pt is tachycardic as well then it would probably point to hemo as hypovolemia is the major difference between pneumo and hemo. After further analyzing it could be a pneumo. You didn’t ask me why it’s happening. All I’m doing is telling you it’s possible for a hemothorax to present with unequal chest rise and I told you why


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## Gurby (Dec 1, 2017)




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## Qulevrius (Dec 1, 2017)

Gurby said:


>



I know, right ?


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## iExposeDeformities (Dec 1, 2017)

You literally said there’s no decreased chest expansion in a hemothorax and that’s what I’m correcting


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## Akulahawk (Dec 3, 2017)

Qulevrius said:


> So per scenario, you have a tachypneac, desatting pt with diminished unilateral chest movement, hemoptysis & OK’sh bp, and that cues you in on hemothorax ?





iExposeDeformities said:


> 100/76 would be considered ok depending on the pulse which we don’t have. If pt is tachycardic as well then it would probably point to hemo as hypovolemia is the major difference between pneumo and hemo. After further analyzing it could be a pneumo.


Given the presentation of the patient as a tachpneic, desatting patient with diminished unilateral chest movement, hemopytysis with a BP of 100/76, I don't think that determining the exact cause of the immediate problem is truly what you need to do. From what I see so far, there's a brewing issue that will very rapidly require immediate action that, if not taken, will result in the death of the patient. The presentation doesn't shout to me "Hi, I'm a hemothorax!" It really doesn't, not a pure one anyway. 

Furthermore, regardless of the patient's pulse rate, I would expect that a BP of 100/76 to be, shall we say, a bit alarming in an adult patient, given the signs we've uncovered. By the book, it's "Ok-ish" but if you think about what's coming very quickly... it should make you very worried about this one.


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## Qulevrius (Dec 3, 2017)

Akulahawk said:


> Given the presentation of the patient as a tachpneic, desatting patient with diminished unilateral chest movement, hemopytysis with a BP of 100/76, I don't think that determining the exact cause of the immediate problem is truly what you need to do. From what I see so far, there's a brewing issue that will very rapidly require immediate action that, if not taken, will result in the death of the patient. The presentation doesn't shout to me "Hi, I'm a hemothorax!" It really doesn't, not a pure one anyway.
> 
> Furthermore, regardless of the patient's pulse rate, I would expect that a BP of 100/76 to be, shall we say, a bit alarming in an adult patient, given the signs we've uncovered. By the book, it's "Ok-ish" but if you think about what's coming very quickly... it should make you very worried about this one.



There’s a lot of ‘what-ifs’ and gaping holes in the scenario. You see one piece of it and go ‘uh-huh’, followed by ‘oh wait’ and ‘uh-oh’. Extrapolating is always fun, just have to remember that this thread was, and still is, a big bad joke.

But if you want my _serious_ opinion on this, then I’d suspect either a major trauma to the rib cage/chest wall (no visual presentation is offered) or a bunch of comorbidities that affected lung integrity.


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## Akulahawk (Dec 3, 2017)

Also per scenario:


jhall98 said:


> Your partner then goes into sudden cardiac arrest


Since you're EMS, chances are pretty good that your partner's SCA is due to caffeine overdose (too much coffee/redbull/etc) touching off Vtach ->VFib... you immediately perform a sharp precordial thump, bringing your partner back from the dead and now you're back to the original problem.


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## Qulevrius (Dec 3, 2017)

Hallelujah, Ahbebangin’.


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## NomadicMedic (Dec 3, 2017)

Qulevrius said:


> Hallelujah, Ahbebangin’.



His name is Fredrick.


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## VentMonkey (Dec 3, 2017)

Qulevrius said:


> Hallelujah, Ahbebangin’.





NomadicMedic said:


> His name is Fredrick.


The dumb ******* almost died.


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## Linny911 (Jan 6, 2018)

I’ve been asking around on this scenario. Everyone I have talked to came to the same conclusion and that was to save your partner. You now have two patients (not MCI), and so you should immediately treat your partner. Your life and your partner’s life matter just as much and even more. This actually happened to my teacher and he said he helped his partner right away.


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