Sasha
Forum Chief
- 7,667
- 11
- 0
I believe Sasha is making preparations for that now.
I am. Keep your fingers crossed for me! I just mailed out two college applications! :]
Follow along with the video below to see how to install our site as a web app on your home screen.
Note: This feature may not be available in some browsers.
I believe Sasha is making preparations for that now.
I am. Keep your fingers crossed for me! I just mailed out two college applications! :]
What and ruin the diploma mill training you got with some real education?
Glad to hear it. Are you going to go ahead and get certified or wait until you graduate the college program?
To be fair, she is describing her experiences with a field preceptor...not her instructor. I'm sure you have seen (as have I) a student medic show up and ride with what ever crew is around...no training provided to that crew in how to precept, how to guide learning, how to teach, or how to lead. It is assumed that because Jane Doe has been a medic for 7 years that she is going to be a capable field preceptor.
Her pulse was irregular, every so often there'd be a missed beat. I never put her on the cardiac monitor. I know I should have, but it slipped my mind, I was focused on respiratory.Thinking back, I'm wondering if maybe the "missed beats" had been due to an irritable heart due to hypoxia.
I assumed her difficulty breathing had been related to her COPD. I know, don't assume! I had kind of tunnel visioned due to the wheezes. It may be worth noting that I thought I had heard both wheezes and some rales, but my preceptor told me you couldn't have both, one or the other which I see now how much of an ignorant statement that was but back in the call I assumed OK, well then there must have been something rubbing on my scope. So wheezes. Let's try to treat it! And even then I dropped the ball. And I'm also really bad at lung sounds. I call something rales, someone else says ronchi kind of thing.
She didn't look heavy or like she had edema above her lower legs.
Before we go into how to treat, I have a quick question. If it had been CHF, would morphine have been an option? I know it causes respiratory depression, but I also know it can reduce preload, and wouldn't a reduction in preload decrease myocardial oxygen consumption?
If your program has critique forms for your preceptors, USE THEM...and don't sugar-coat them either. Granted there are times that you may feel like they don't work, but I'm sure if enough students have the same gripes about the same few preceptors, some action would (should) be taken. If nothing gets done at the class level, I would suggest taking it up the chain - even if it means talking to the medical director himself. Extreme, perhaps...but this is YOUR education, not theirs.
It's a tough road to "narc" on bad preceptors, especially if your school lets you ride at one or two agencies. Compounding that fact is the reality that these preceptors were probably trained at the same facility by the same instructors who have some rapport with each other.
Ok. I typed this last night but the darn site was down!!
I was intially thinking CHF because of her history of CAD and the edema, before the family had stated that was normal for her. Also because she has a history of COPD, but the "I can't breathe!" only started very recently. Also because the position of her pillows in her bed and in her chair had her sleeping near upright. I didn't think pneumonia simply because she didn't feel hot, I know that people who are immunosupressed often present without fever, but based on her med list and history there was nothing that jumped out and screamed "immunosupression!". The only reason I went with her dyspnea being related to COPD had been the wheezes and hx of COPD.
Ok, treating this patient. I think early transport would be vital. I don't think I would have even gone to an NRB/NC, probably straight to CPAP with nebulized albuterol, force air into her lungs, fluid out, and bronchiodilate. I imagine having bronchioconstriction with CHF makes it even harder to breathe, so bronchiodilation could only be beneficial, right? And even it had been her COPD and not CHF, CPAP wouldn't have been contraindicated, right?
Also put her on the cardiac monitor.
So, after that, we would want to reduce preload, right? Sublingual nitro should vasodilate, which reduces venous return, reducing preload.
And now I'm stuck. What else could have been done? What next?
...because the position of her pillows in her bed and in her chair had her sleeping near upright. The only reason I went with her dyspnea being related to COPD had been the wheezes and hx of COPD.
Also, CPAP doesn't really force the fluid out; it improves the ability of the alveoli to diffuse oxygen to the red blood cells by using pressure to drive gas into the alveoli and open up unused or collapsed alveoli. I used to think CPAP pushed the fluid out...I was harshly corrected by an instructor who was having a bad day (or so it seemed).
Also, CPAP doesn't really force the fluid out; it improves the ability of the alveoli to diffuse oxygen to the red blood cells by using pressure to drive gas into the alveoli and open up unused or collapsed alveoli. I used to think CPAP pushed the fluid out...I was harshly corrected by an instructor who was having a bad day (or so it seemed).
be happy that you have something besides O2 and Albuterol; that is all we have and we have a miminum of a 45 min transport. I have had a 1hr 45 min transport a few weeks ago, and that is to a small hospital. If we need a bird, it may be 20-30 min to meet them, (and we don't wait, we start transporting).
I've been reading Sasha's post and have been thinking along the lines of sedating this patient. I've never had a combative patient like this...of course now that I've said that my next call will be probably a combative 400 lb CHF'er on the second story.
I can't RSI where I work, so all I can do is sedate with Versed. I will use Versed when the time comes that I do get a patient who's very combative and can't be managed, but I'm afraid that after I give it I'll end up with a patient who's knocked out and barely breathing. Can you guys with more experience handling such patients relate your experiences? Thanks; hope I'm not highjacking the thread too much.