DrParasite
The fire extinguisher is not just for show
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a little backstory on this call:
i just started a new part time job, in a new county, for awesome pay in an area that's not all that busy. It's a BLS 911 and IFT agency, handing BLS calls for the town and for calls meeting ALS criteria a paramedic flycar is requested from a hospital.
It was my first shift on the truck, and due to a scheduling snafu, I was assigned as a 3rd, instead of a 2nd. I was also informally educated about how the ALS agency's crews aren't the nicest to BLS crews, and has a bad habit of walking in and asking BLS crews "so are we cancelled????" on every call, and really giving crews a hard time on calls that they are not cancelled for that that don't obviously need an ALS assessment or intervention. Suffice it to say, I was a little disturbed by what I heard, but I'm a big boy, and every place has their quirks, so whatever.
and the night is dead. slooooow. we have 3 trucks on, and in 8 hours, neither truck has done anything. i'm crawling the walls from boredom. completely not used to this
Anyway, we get a call for a difficulty breathing. pt is an elderly gentleman from another country with a language barrier who is found sitting on the floor with a nebulizer in his mouth recieving a treatment. hx of copd, and htn, prescribed a combivent and htn meds which he hasn't taken all day. Pt is grossly diaphoretic, w/ JVD present. NRB is applied at 15 lpm, and patient immediately pulls it off.
my working diagnosis at this point is that he's in heart failure, and his lungs are full of fluid (based on my experience that I have seen people with CHF act exactly like this after they have flashed, since they feel like they are drowning). a quick BP is assessed, found to be 260+/140, and a listen to his lungs reveals rales all the way up on both sides. He is still fighting the NRB, and we are trying to get him to have it stay on. We get him into the stairchair, and carry him down the stairs to the ambulance, where the ALS are just arriving.
Now, I have a pretty sick patient, and don't want to deal with anyone asking me "so do you really need us?" Thankfully the medic is someone who I have known for 5 years, have worked on a BLS 911 truck together, and doesn't have that attitude at all. He asked for a report on what has happened, and what I think is going on, and I tell him, and they begin treating the patient
I'm thinking they are going to CPAP this (still conscious) patient. They establish IV access, give lasix, followed by 2 nitro sprays. still no cpap. an OPA is inserted, and the patient doesn't tolerate it. He is still sitting up on the cot w/ a gag reflex, and the paramedic says he is going to intubate the patient. I asked him if he wants to try cpap, and he tells me because he won't tolerate the NRB, CPAP isn't an option. They push versed and a sedative, and the medic does a face to face intubation, and we end up bagging the patient in a seated position until we get to the ER.
here are my questions: once you intubate a CHF patient w/ pulminary, should you lay the person down or keep them sitting up? does it matter? this is the first time i can recall bagging a sitting up person who was intubated.
on intubate vs CPAP, when is CPAP no longer an option on a conscious patient? when intubated, can a patient be easily extubated, or will they be on a vent for a while?
is it standard practice on CHF people that if a patient can't tolerate a NRB to immediately go to intubation?
not bad for my first call at the new place, and it turned out to be the only call for all 3 trucks for all 12 hours of the shift.
i just started a new part time job, in a new county, for awesome pay in an area that's not all that busy. It's a BLS 911 and IFT agency, handing BLS calls for the town and for calls meeting ALS criteria a paramedic flycar is requested from a hospital.
It was my first shift on the truck, and due to a scheduling snafu, I was assigned as a 3rd, instead of a 2nd. I was also informally educated about how the ALS agency's crews aren't the nicest to BLS crews, and has a bad habit of walking in and asking BLS crews "so are we cancelled????" on every call, and really giving crews a hard time on calls that they are not cancelled for that that don't obviously need an ALS assessment or intervention. Suffice it to say, I was a little disturbed by what I heard, but I'm a big boy, and every place has their quirks, so whatever.
and the night is dead. slooooow. we have 3 trucks on, and in 8 hours, neither truck has done anything. i'm crawling the walls from boredom. completely not used to this
Anyway, we get a call for a difficulty breathing. pt is an elderly gentleman from another country with a language barrier who is found sitting on the floor with a nebulizer in his mouth recieving a treatment. hx of copd, and htn, prescribed a combivent and htn meds which he hasn't taken all day. Pt is grossly diaphoretic, w/ JVD present. NRB is applied at 15 lpm, and patient immediately pulls it off.
my working diagnosis at this point is that he's in heart failure, and his lungs are full of fluid (based on my experience that I have seen people with CHF act exactly like this after they have flashed, since they feel like they are drowning). a quick BP is assessed, found to be 260+/140, and a listen to his lungs reveals rales all the way up on both sides. He is still fighting the NRB, and we are trying to get him to have it stay on. We get him into the stairchair, and carry him down the stairs to the ambulance, where the ALS are just arriving.
Now, I have a pretty sick patient, and don't want to deal with anyone asking me "so do you really need us?" Thankfully the medic is someone who I have known for 5 years, have worked on a BLS 911 truck together, and doesn't have that attitude at all. He asked for a report on what has happened, and what I think is going on, and I tell him, and they begin treating the patient
I'm thinking they are going to CPAP this (still conscious) patient. They establish IV access, give lasix, followed by 2 nitro sprays. still no cpap. an OPA is inserted, and the patient doesn't tolerate it. He is still sitting up on the cot w/ a gag reflex, and the paramedic says he is going to intubate the patient. I asked him if he wants to try cpap, and he tells me because he won't tolerate the NRB, CPAP isn't an option. They push versed and a sedative, and the medic does a face to face intubation, and we end up bagging the patient in a seated position until we get to the ER.
here are my questions: once you intubate a CHF patient w/ pulminary, should you lay the person down or keep them sitting up? does it matter? this is the first time i can recall bagging a sitting up person who was intubated.
on intubate vs CPAP, when is CPAP no longer an option on a conscious patient? when intubated, can a patient be easily extubated, or will they be on a vent for a while?
is it standard practice on CHF people that if a patient can't tolerate a NRB to immediately go to intubation?
not bad for my first call at the new place, and it turned out to be the only call for all 3 trucks for all 12 hours of the shift.
