# Call that turned bad quick!



## tazman7 (Aug 28, 2008)

Went on a good call today during my paramedic ride time. 

Got called for a 65 year old male that passed out had a seizure and feels dizzy. We get there and there is the guy laying on the floor, sweating with his head in a puke bucket. We start asking him questions, medical history reviels hes on dialysis, history of hypertension and has had a couple seizures in the past, but they never found out why. So we get the cot next to him and he seizes again for about 10 seconds and wakes up and is kinda alert. Get him in the ambulance, start iv, monitor, vitals. vitals are stable monitor shows nsr with a rate of 100, blood sugar of 127. Pt denies chest pain. We asked him if he was having cp and sob about 15 times during transport. We get about a block from the hospital guy says hes having sob and a wierd feeling in his chest. We wheel him in the ed and as soon as we get through the doors, he seizes, codes and dies.

I cant believe how the call went from being ok to having a huge pucker factor. Goes to show crazy stuff can happen in a blink of an eye, great learning experience for me.


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## tazman7 (Aug 28, 2008)

After thinking about it is that my diagnosis of his death would be he was having a massive MI that we couldnt see with just a 3 lead.. I think if we had a 12 lead on our ambulance we would have seen it.

Thoughts?


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## KEVD18 (Aug 28, 2008)

you probaly have seen something on the 3 lead. while you certainly cant diagnose mi with 3 leads, it will normally show _something_.

while you cant rule out ami since you couldnt do a XII lead, i thinks its unlikely. although im sure if im wrong, somebody will be along to slap me back into place.

is there any system in place for ems follow up? id be interested to hear the post report.


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## Ridryder911 (Aug 28, 2008)

Learning experience 101. The sounds of hoofs beats may not always be horses; rather it maybe zebras! Meaning, things may not always appear to be what they are. 

Lesson 101. Your patient hx. of Dialysis therapy should have been the red flag.. no take that back.. Flares going off.  There is great potential problems with this patient. Dialysis patients are walking time bombs. Want to hear critical lab values, just have a dialysis patient. These folks K+, Na+, Cl-, Mg+ are always teeter tottering on the brink of disaster.
Any change such as N & V, diarrhea can cause disaster in electrolytes and fluid balances. A sudden change in electrolytes can cause arrhythmias, seizures and sudden death. 

A word of wisdom.. Any patient that is truly diaphoretic is serious. This is the body's way of attempting to adjust things.. This is Gods way of letting us know to watch and take these patients serious. This is a *serious warning sign*. Sure, some people get clammy after vomiting, but again is it transient, do they have an outstanding hx.? All good things to think about. Again, learn off this patient. Be prepared next time. 

There are times, that some calls will catch you off guard. Patients with a significant history, one should get mentally prepared for anything. 

R/r 911


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## VentMedic (Aug 28, 2008)

Dialysis patients are probably the biggest train wrecks waiting to happen you can have in your truck. Unfortunately the EMT or Paramedic does not get enough education about electrolyes and all that boring stuff about renal function or how every organ in the body can be affected when the body's chemistry is just a little off. Even with just the K+ level being a little on the high side, many symptoms can manifest from that. Unfortunately in EMS education, everything is an MI or SOB without really understanding the processes that got the patient to that point. There are a lot of hypers and hypos that can bring about the symptoms described which may or may not have EKG changes. A 12 lead would also be more helpful as KED mentioned.

Not saying that it is not a good thing to focus on MIs but one must also be able to know what else goes with certain disease processes.  Tunnel vision with only a few disorders skews your assessment.


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## tazman7 (Aug 28, 2008)

Wow, thanks guys!

So what could have we done for this poor guy?


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## mycrofft (Aug 29, 2008)

*So many aspects...*

A classic grand mal seizure which ends with the patient becoming alert is a rarity, well nigh an impossibility. However, many episodes of cerebral anoxia, including a simple vaso-vagal syncope in a shot line, or cardiac shutdown, can result in "funky chicken".
If this guy was truly teetering from dialysis issues, given the short time between contact and arrival for defintive care, there is little you could do. Electrolytic cardiac standstill is tricky to reverse in hospital much less in ambulance; it was Dr Kavorkian's (and is the State of California's) "K+iss goodbye". 
Of course, we can't eliminate CVA (aided by/causing vomiting), neoplasm, or bum ticker unassociated to or aided and abetted by the renal issue.

Massive MI would show up on 3 lead. It could "show up" on cardio ausc or carefully palpated pulse for over a minute, if not less, as a frank arrythmia.


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## Outbac1 (Aug 29, 2008)

I had a guy, (younger only 39), like that a couple of years ago. Picked him up weak with N&V and due for his dialysis. He coded about 10 min after arriving at the ER. The Drs took a chance while working the code,(my partner and I assisted), and as the monitor showed torsades gave him calcium and mag sulfate. He had coded before labs were done so they took an educated guess. It worked. After 40 min of working the code we got him back. He went for dialysis the next AM and was discharged a few days later fully functional. However he subsequently put a DNR in place and died a couple of months later. He was just tired of living the life he had.

 As Rid said a great learning experience. It would be nice to know what his labs were and what they did during the code that may have been a bit different than the "norm" eg: epi,atropine, lidocaine.


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## Ridryder911 (Aug 29, 2008)

What would I do differently is try to obtain a good adequate history. History, history, history is one of the major assessments on a medical call.. (Did I mention history?).  Last Dialysis treatment, change in bath solution, illness prior to event, last meal, reason why the patient is on dialysis for renal failure? HTN, DM or poor renal clearance? Treat accordingly. Patient appears postictal, post N & V? 


DANGER WILL ROBINSON!

Get prepared, be sure to maintain adequate oxygenation per N/C (since they are vomiting). IV access if possible mean while obtaining an XII lead ECG (noting for peaked or malformed T wave, P-R changes, as well as QRS modifications) Assess for glucose problems, checking FSBS and tx appropriately. Thinking a high possibility of a  potential electrolyte and even hypovolemia. How much fluid did they remove? (check pre and post weight). Look for tremors, Trousseau sign or Chvostek's sign that can easily be tested in the field checking for hypocalcemia which is also r/t increased ammonia ranges. Treat the seizure accordingly. If no IV access, then nasal Versed. Watch fluid intake, no need to drown them. 

Like Vent and I described, these folks are unforgiving and will die on you immediately. Unfortunately most medics do not pay attention and get tunnel vision on the post history or unaware the potential problems until too late. 

R/r 911


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## MSDeltaFlt (Aug 29, 2008)

Yeah, with him seizing and being on dialysis, I'm thinking his K+ was somewhere in the neighborhood of 7.  Just a thought.


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## Ridryder911 (Aug 29, 2008)

I actually had a Dialysis cardiac arrest yesterday. Upon arrival the patient was on dialysis machine was getting a defib shock from the AED, no ROSC. Fortunately the dialysis nurse was a former career Paramedic (18 years). I  was able to use the shunt for IV access and immediately administered Epi and applied my monitor to be able to view. Difficult to determine with a possible V-tach type complex, bizarre wide QRS. I asked for the pre-dialysis base line labs. The  critical values were K+ was 9.15, Na+ was 120. I administered 4mg of Mg+ and 25 meq of NaHCo3 (for sodium and volume replacement). Spontaneous pulse occurred in about 3 minutes. This is not unusual due to the cardiac arrest  etiology is not caused by coronary occlusions rather by electrical/nervous system disruptions. 

In fact, my success rate is much greater on immediate post dialysis patients than on true coronary patients. 


I found a link with the "normal" lab readings of dialysis patients. I changed the wording a little: I keep a copy in my field guide to refer to for ill dialysis patients. Usually such centers have a recent copy of current labs. True, the treatment may not change, but being able to focus on the problems helps makes a better diagnosis.


*Those with dialysis *:* (NOT NORMAL LAB VALUES!!!)*
Albumin
Albumin is a protein that transports many small molecules in the blood. Albumin also keeps blood from leaking into the surrounding tissues.

For adults, an albumin level of 3.5 to 5.0 grams per deciliter (g/dL) is desirable — whether you're on dialysis or not. Lower levels may suggest that you're not eating enough protein.

* Blood Urea Nitrogen, BUN*
Urea and nitrogen are waste products created when protein is broken down in your body. Dialysis helps rid of these body wastes. The amount left in the blood indicates how well the dialysis is working.

For adults on dialysis, a blood urea nitrogen level less than 65 milligrams per deciliter (mg/dL) is desirable just before a dialysis session. The doctor (Nephrologist) will monitor the rate of reduction of the blood urea nitrogen level during dialysis to help determine how much dialysis they need.

*Calcium, Ca+*Calcium supports bone growth and normal heart and muscle function. If your calcium level is too low, your bone density will suffer.

For adults on dialysis, a calcium level of 8.5 to 10.0 mg/dL is desirable. Lower levels may suggest that you're eating too many phosphorous-rich foods, such as dairy products, whole grains and nuts. Higher levels may suggest that you're getting too much supplemental calcium or vitamin D or developing a bone disease known as renal osteodystrophy, a common problem in people with kidney disease and those receiving dialysis.

*Creatnine, Creat*
Creatnine is a waste product produced by your muscles and, to some extent, from the meat in your diet. The amount of creatinine in your blood indicates how well your kidneys are functioning.

If the patient is on dialysis, the most desirable creatinine level can vary depending on how muscular they are, the type of dialysis they chose and how much kidney function they have left. High creatinine levels may suggest that dialysis is inadequate or that their not consuming enough calories.

Ferritin
Ferritin is a protein that stores iron in the body. The amount of ferritin in your blood is directly proportional to the amount of iron available in your body to produce hemoglobin — the protein that carries oxygen in the blood.

For adults on dialysis, a ferritin level of 200 to 500 micrograms per liter (mcg/L) is desirable. Higher levels may indicate inflammation or simply follow repeated blood transfusions. Lower levels may suggest that they are not absorbing enough iron from their iron supplements.

Folate
Folate helps produce and maintain new cells.

For adults on dialysis, a folate level higher than 20 mcg/L is desirable. Lower levels may suggest that you're not taking your dietary supplements.

Glycated hemoglobin (HbA1c)
If you have diabetes, your doctor may do a glycated hemoglobin test to determine how well you're managing your blood sugar. The test reflects your average blood sugar level for the two- to three-month period before the test.

For adults, a glycated hemoglobin level of 7 percent or less is desirable — whether you're on dialysis or not. Higher percentages indicate poor blood sugar control.

*Hematocrit, HCT*
Your hematocrit is the percentage of red blood cells in your blood.

For adults on dialysis, a hematocrit of 33 percent to 36 percent is desirable. Lower percentages may suggest that you've lost some blood, your iron level is too low or your dosage of erythropoietin — a hormone normally produced by the kidneys — needs to be adjusted.

*Hemoglobin, Hgb*
Hemoglobin is the protein that carries oxygen in the blood.

For adults on dialysis, a hemoglobin level of 11 to 12 g/dL is desirable. Lower levels may suggest that you've lost some blood, your iron level is too low or your dosage of epoetin alfa (Epogen, Procrit) or darbepoetin (Aranesp) needs to be adjusted.

Iron
Iron works with protein to make the hemoglobin in red blood cells. Iron is stored in the liver, spleen and bone marrow.

For men, an iron level of 50 to 150 mcg/L is desirable — whether you're on dialysis or not. For women, the desirable range is 35 to 145 mcg/L. Higher levels may follow repeated blood transfusions. Lower levels may suggest that you're not absorbing enough iron from your iron supplements.

Your doctor may also measure the percent saturation of iron in the blood, which indicates how much usable iron you have in your blood. A value higher than 20 percent will improve your body's response to epoetin alfa (Epogen, Procrit), a hormone that stimulates the bone marrow to produce red blood cells. Higher percentages may follow repeated blood transfusions. Lower percentages may suggest that you're not absorbing enough iron from your iron supplements.

Parathyroid hormone
Parathyroid hormone balances your calcium and phosphorus levels.

For adults on dialysis, a parathyroid level of 5 to 15 picomoles per liter (pmol/L) is desirable. Higher levels may suggest poor calcium and phosphorus control or overactive parathyroid glands.

Phosphorus
Phosphorus plays an important role in bone health. The mineral also helps maintain a normal acid-base balance (pH) in your body. High levels of phosphorus can deplete your blood of calcium. Low levels of phosphorus can lead to muscle weakness.

For adults on dialysis, a phosphorus level of 3.0 to 5.5 mg/dL is desirable. Higher levels may suggest that they have eaten too many phosphorous-rich foods or that you've taken too little phosphate-binding medication or haven't taken it with your meals. Lower levels may suggest that they have taken too much phosphate-binding medication or aren't consuming enough protein or calories.

*Potassium, K+*
Your body needs potassium for normal heart and muscle function. Potassium levels too high or too low can slow or stop your heart.

For adults on dialysis, a potassium level of 3.5 to 5.5 milliequivalents per liter (mEq/L) is desirable. Vomiting and diarrhea can cause lower potassium levels. Higher levels may suggest that their eating too many potassium-rich foods or too much food in general.

*Sodium, Na+*
Your body needs sodium to function properly. Low levels of sodium can cause muscle cramping, confusion and seizures. High levels of sodium can cause excessive thirst. Extremely high levels can lead to confusion and seizures. As well as extreme low sodium.

For adults, a sodium level of 135 to 145 mEq/L is desirable — whether you're on dialysis or not. Lower levels of sodium may indicate that they are retaining too much fluid.

Vitamin B-12
Vitamin B-12 helps form red blood cells and maintain a healthy nervous system.

For adults on dialysis, a vitamin B-12 level of 200 to 650 nanograms per liter (ng/L) is desirable. Lower levels may suggest that they are not absorbing enough vitamin B-12 from their dietary supplements.

Other tests
*PT*: How long it takes the blood to clot (prothrombin time). If the result is high, the blood is too thin and their at greater risk of bleeding. If it's low, the blood is too thick and may clot in the dialysis machine or within the venous access point.

Your doctor may also test for blood for signs of exposure to hepatitis B or hepatitis C, serious infections that can spread through contact with contaminated blood.

Cholesterol and triglyceride tests are common as well. Higher levels of low-density lipoprotein (LDL), or "bad," cholesterol and lower levels of high-density lipoprotein (HDL), or "good," cholesterol increase the risk of heart disease, as can high levels of triglycerides

Hope this helps!

R/r 911


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## tazman7 (Aug 29, 2008)

I wasnt lead medic on the call so I missed half of the history taking because I was trying to manuever the cot into the trash filled house.


 Not quite sure what the guy was on dialysis for.

During the code the Dr. turned it into a cf (cluster f***). Initial rythm was NSR that then went bradycardic around 30, then 20. Then it took the er nurses approx 2 minutes to even put the monitor back on the pt. Dr then ordered calcium chloride and something else first, not sure what it was. Then epi and atropine. Rythym then switched to v-fib, we shocked him with 200j and the dr continued to give epi/atro...i said how about we try lido since its v-fib and he looked at me with a confused look and said lets push 100mg lido. shocked pt about 3 times and then went asystole, we worked it for another 10 minutes and dr called it.

Looking back at it now, there may have been a little st-elevation but it was borderline, other then that is was nsr.


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## newbie (Aug 29, 2008)

KEVD18 said:


> while you certainly cant diagnose mi with 3 leads, it will normally show _something_.
> 
> while you cant rule out ami since you couldnt do a XII lead, i thinks its unlikely.



To the best of my knowledge both of the above statements are wrong.
With respects to the first statement you can diagnosis STEMI's (ST segment elevated MI's) with a 3-lead monitor.  In order to do that your monitor needs to be printing in the diagnostic mode, that means a frequency response of 0.5-40 mhz.  Once in said mode you need 1mm or more of ST elevation in 2 or more contiguous leads.  The 3 lead view in fact gives you 6 leads; I, II, III, aVF, aVL, and aVR.  II, III and AVF are contiguous leads.  They show the inferior portion of the heart.  50% of STEMI's show here.  Also I and aVL are contiguous leads.  They show the lateral portion of the heart.  You have two opportunities to D'x a STEMI with a three lead provided you have it set to the correct mode and then have it display contiguous leads. 
The second statement is also problematic.  Only 1/2 of MI's are STEMI's.  That means the half, 50% of MI's do not show up on an EKG!  A 12-lead does NOT rule out an MI!
J


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## Ridryder911 (Aug 29, 2008)

Actually one should not base their readings strictly upon ST elevation alone. Remember, reciprocal changes as well. I am not saying one cannot display ST elevation and with the associated clinical symptoms assume it is an AMI. I am stating one should not base ST elevation on a three lead configuration. Yes, one use MCL1 as well as move leads to see the usual 9 as in Multilead medics from Bob Pages description and from us old medics that used this before XII lead capability. Just using a three lead as a monitoring device does not give enough information. That is why, those that view in three cannot see...


R/r 911


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## rhan101277 (Aug 29, 2008)

I wonder if more advanced training above paramedic is in the future for EMS.  Don't know what it would be called, but anyone with more advanced training and a scope of practice to use it could save more lives.


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## KEVD18 (Aug 29, 2008)

newbie said:


> To the best of my knowledge both of the above statements are wrong.
> With respects to the first statement you can diagnosis STEMI's (ST segment elevated MI's) with a 3-lead monitor.  In order to do that your monitor needs to be printing in the diagnostic mode, that means a frequency response of 0.5-40 mhz.  Once in said mode you need 1mm or more of ST elevation in 2 or more contiguous leads.  The 3 lead view in fact gives you 6 leads; I, II, III, aVF, aVL, and aVR.  II, III and AVF are contiguous leads.  They show the inferior portion of the heart.  50% of STEMI's show here.  Also I and aVL are contiguous leads.  They show the lateral portion of the heart.  You have two opportunities to D'x a STEMI with a three lead provided you have it set to the correct mode and then have it display contiguous leads.
> The second statement is also problematic.  Only 1/2 of MI's are STEMI's.  That means the half, 50% of MI's do not show up on an EKG!  A 12-lead does NOT rule out an MI!
> J




sorry sir, but you're mistaken. a III lead can give you an idea, but you need a XII to diagnose(i know, i know, we dont dx int he field...).

R/r is much more eloquent than i am and can explain it better.


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## VentMedic (Aug 29, 2008)

rhan101277 said:


> I wonder if more advanced training above paramedic is in the future for EMS. Don't know what it would be called, but anyone with more advanced training and a scope of practice to use it could save more lives.


 
You do have advanced providers who have taken additional training and education for Flight and some CCT. You read an example of this with the scenarios I posted about trauma and sepsis. They were beyond the education of the average paramedic.

EMS needs to get some standards established and gather up the 50+ different certifications/licenses this profession to make just a couple of licensed professional providers.


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## KEVD18 (Aug 29, 2008)

rhan101277 said:


> I wonder if more advanced training above paramedic is in the future for EMS.  Don't know what it would be called, but anyone with more advanced training and a scope of practice to use it could save more lives.



it already exists. there was an article in jems oh maybe 18 months ago regarding what they were calling advanced practice paramedics. something along the lines of a cross between a paramedic and a pa. basically it broke down like this. you roll up on the scene of a medical and find out its a humdinger of a head cold. so you do an exam and make your call that its nothing more than a head cold. you call the doc, give him your exam finding, he chews on it and decides you're right. you give the patient follow up care instructions, maybe even write a prescription for abx and clear the scene. no transport needed.

it wouldnt be a perfect system. people would abuse it as a home care service. it would also be a little tricky in the beginning for the doc to decide what calls to treat on scene and what needed t/p without labs and diagnostic imaging but all in all the idea shows promise.


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## emt19723 (Aug 31, 2008)

Ridryder911 said:


> Learning experience 101. The sounds of hoofs beats may not always be horses; rather it maybe zebras! Meaning, things may not always appear to be what they are.
> 
> Lesson 101. Your patient hx. of Dialysis therapy should have been the red flag.. no take that back.. Flares going off.  There is great potential problems with this patient. Dialysis patients are walking time bombs. Want to hear critical lab values, just have a dialysis patient. These folks K+, Na+, Cl-, Mg+ are always teeter tottering on the brink of disaster.
> Any change such as N & V, diarrhea can cause disaster in electrolytes and fluid balances. A sudden change in electrolytes can cause arrhythmias, seizures and sudden death.
> ...



wow...good post there Rid!  gonna keep all that in the back of my mind cuz we have a dialysis clinic in our first due area and we go there at LEAST 3-5 times a week.


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## MySandie (Jun 30, 2013)

Re: the call that went so bad after, apparent stable VS + N/V that lead to DOA:



VentMedic said:


> Dialysis patients are probably the biggest train wrecks waiting to happen you can have in your truck. Unfortunately the EMT or Paramedic does not get enough education about electrolyes and all that boring stuff about renal function or how every organ in the body can be affected when the body's chemistry is just a little off. Even with just the K+ level being a little on the high side, many symptoms can manifest from that. Unfortunately in EMS education, everything is an MI or SOB without really understanding the processes that got the patient to that point. There are a lot of hypers and hypos that can bring about the symptoms described which may or may not have EKG changes. A 12 lead would also be more helpful as KED mentioned.
> 
> Not saying that it is not a good thing to focus on MIs but one must also be able to know what else goes with certain disease processes.  Tunnel vision with only a few disorders skews your assessment.



One would think that as a 1st responder, EMT-B through EMT-P training would include more about pathophysiology and electrolyte levels.  Heck, even in my BSN program, I didn't learn that right vagus hyperstimulation --> bradycardia, and that left vagus hyperstimulation-->  AV block, both of which could lead to death, even with NO chest pain and relatively stable VS.

All I was taught was that typical MI S/S in a male = chest pain that TENDS to radiate to left side/back + N/V, and that in females, pain + radiation may not even exist.  Also, only taught that N/V causes vagus stimulation --> bradycardia --> decreased O2  --> decreased LOC (syncope), which is why an RN needs to assess LOC and vitals after N/V.  But, it was never pointed out how dangerous N/V can be.  The 'devil is in the details' which doesn't seem to be highlighted for 1st responders *or* RN education (at least in my BSN program---which was an accelerated 17-month course).

It wasn't until studying for the NCLEX-RN exam did I learn how dangerous N/V symptoms can be, and that it can, actually, lead to death.  This is partly why I find the emtlife.com site so :censored: fascinating!

Experience is the true medical professor.

Okay...I'm REALLY going to log-off now, and get back to it!  :rofl:


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## Craig Alan Evans (Jun 30, 2013)

Ridryder911 said:


> Learning experience 101. The sounds of hoofs beats may not always be horses; rather it maybe zebras! Meaning, things may not always appear to be what they are.
> 
> 
> A word of wisdom.. Any patient that is truly diaphoretic is serious.
> ...



These two sentences are golden nuggets. All that shakes is not seizures is another one more specific. 

Did you have 12 lead capability? That's one of the first things I would have done with this guy. 

He sounded like a critical patient from the start, but EMS education does not do a very good job of preparing you for a patient like that.  Lessons like that are unfortunately the most difficult ones but also the most memorable. Study up on 12 and 15 lead EKGs, hyperkalemia, acute renal failure, fluid overload in acute renal failure, and that should give you a better understanding of what may have happened. 

Pay very close attention to everything that is said and done in the ER when you bring in a critical patient like that. If you don't understand a treatment modality or anything that is said or done then look it up afterwards and study. Medicine is constantly evolving and you have to keep up. The education you get to become certified just scratches the surface.


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## NomadicMedic (Jun 30, 2013)

Be aware this thread is from 2008 and none of the original contributors are available to answer any questions or provide further information.


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